2005・7
Comparative Analysis of Organizational Commitment
in Medical Professionals

高田壮豊

TABLE OF CONTENTS
PageI. Introduction
I-1
Motivation for this study
I-2
Professional sub-culture in the medical institutions
I-3
The purpose and research question of the study
I-4
Design of this study-------------------------------------------------------------------------------------------

1
1
2
2
3

II. Literature review for the previous studies
II-1 Human resource management in medical and health care service
II-2
Resource based view in human resource management
II-3
Organizational commitment
II-4 Self-actualization
II-5 Fundamental values of medical professionals-------------------------------------------------------------------------------------------------------------

4
4
5
7
8
10

III. Survey of motivation and commitment in medical professionals
III-1 Conceptual framework of the study
III-2 Definition of the model and rationale
III-3 Hypotheses formation
III-4 Data collection proceduresIII-4.1 Sample and procedure
III-4.2 Measures and questionnaire design
III-4.2.1 Organizational Commitment Scales
III-4.2.2 Short Index of Self-Actualization
III-4.2.3 Japanese form of for the individual data sheet
III-5 Data analysis
III-5.1 Procedures and data distribution
III-5.2 Descriptive statistics and correlation
III-5.3 Analysis of variance and multiple comparison
III-5.4 Two-sample t-test
III-5.5 Multiple linear regression analysis
III-5.6 Path analysis of commitment in medical professionals
III-5.6.1 Correlation within the commitment components
III-5.6.2 Multivariate regression analysis
III-5.7 Findings of the analyses
III-6 Verification of hypothesis
III-7 Practical implications and limitations-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

14
14
15
16
17
17
17
17
18
18
19
19
20
21
22
22
23
23
23
25
26
26

IV. Theoretical perspectives of medical professionals
IV-1 Historical cultivation of medical professionalism
IV-1.1 History of medicine
IV-1.2 Formation of medical professionals
IV-2 Hippocratic Oath and medical professionalism
IV-2.1 Hippocratic Oath in medical history
IV-2.2 Request of Hippocratic Oath in medical professionals
IV-3 Insights through historical and cultural approachIV-4 Theoretical perspectives-------------------------------------------------------------------------------------------------------------------------------------------------------------------

27
28
28
29
30
30
32
34
35

V. Concluding remarks-------------------

37

REFERENCES-------------------

38

APPENDICES-------------------

41

Comparative Analysis of Organizational Commitment in Medical Professionals
Moriatsu Takada, MD, PhD, MBA

I.

Introduction

I-1

Motivation for this study

I have been working as a medical doctor for sixteen years, hospital to hospital, in various kinds of
medical institutions. Most of them are private hospitals, emergency and primary care, staying at coldnight with fear of listening the siren from the ambulance.
In my younger and more vulnerable years spending as a resident, I have working in the educational
hospital during the daytime earning money with duty business in such private hospitals. We have to
pay attention to nurses in the teaching hospital, but not in private hospital because they are working
under the doctor’s order. One day, my senior gave me some advise that I’ve been turning over in mymind ever since. He said, “You cannot work as a doctor if nurses dislike you, just remember that all
the nurses in this world have the advantage more that you’ve had.” He did not say any more but I used
to buy some souvenirs, such as dessert cake or sushi, whenever we go drinking with my fellows. I
understood that he meant a great deal more than that.
Since then, I have a curious feeling to the paramedical staffs, with different nature, looking uponthem as another group. “Watch them, as they are not doctors…,” and as I grown up, I have realizedthat they also have such a feeling of “ Watch them, they are not nurses”, in turn. This is the so-called“chicken and egg situation”, but it actually exists some big and tall walls between the professional1
groups who have license of national qualifications. This feeling of constraint is getting bigger while I
move from hospital to hospital and find some differences in nature that they have.
The category of hospital, as public hospital through private hospital, seems to be a major factor that1

According to the American Heritage Dictionary of the English Language (Fourth Edition, 2000), the word of “professional”
is defined as (i) a person following a profession, (ii) one who earns a living in a given or implied occupation and (iii) askilled practitioner; an expert. In this study, the third meaning of professional would be applied. Besides, the word of“specialist” is defined as (i) one who is devoted to a particular occupation or branch of study or research. (ii) a physician
whose practice is limited to a particular branch of medicine or surgery, especially one who is certified by a board ofphysicians. Note that the meaning of these two words is different and should be distinguished.

1prescribes their natures. As I have been interested in the difference of such feeling between the
medical professionals, I would like to make it clear to keep a good relation and utilize them for thehospital management. This is the start point of and the motivation for the current investigation.

I-2

Professional sub-culture in the medical institutions

Professional sub-cultures seen in medical staffs of the hospital, in the sense of autonomy, seem to benecessary for them to have responsibilities to their work. Nevertheless, such sub-groups accompanying
tall walls involuntarily make some barrier against total quality management, clinging to their own
privileges without a bird’s-eye view for their hospitals. Recent report2, a purposive survey performedin seventeen European Union countries, has shown that there are many health professionals who have
only a superficial understanding at best. As medical science progresses, multidisciplinary teamwork is
required to perform the complicated health care service with the total quality management.
Besides, the liberty of their own work should be guaranteed in the professional point of view,
because intolerable constraints lay them aside to seek another better environment. As to hospital, themedical manpower is definitely necessary in professional organization and career structure is the issue
to be considered3. Different from other professionals, it is easy for the medical professionals can rather
to find their new positions, so called turnover4. In that sense, human resource management in medical
professionals is rather difficult than others and their satisfaction, rewarded for their work andresponsibilities as professionals, seems to be a key factor in the human resource management for
medical professionals5.

I-3

The purpose and research question of the study

The purpose of the current study is to identify the determinants that may impact the organizational
commitment of medical professionals after clarifying their features based on the category of the2

Hindle (2005)
Vickers (1981)
4
In common parlance, "turnover” means loss of an employee, voluntary or involuntary termination. Mathematically, turnoveris defined as total terminations per unit time divided by the average active number of employees per same unit time.
5
Savage (2004)
32

hospitals. Hasenfield6 has classified organizations as three types corresponding to the three major
sectors of the economy: public, non-profit, and for-profit. According to the Japanese Health Law(Article No. 4), the public hospital is defined as the hospitals established by the government, such as
national or municipal hospital, in order to secure and support medical treatment in the concerned
region. In the present study, the hospitals are classified as follows:∗

university hospital that is founded by Ministry of Education7 for the research and educational
purpose that is attached to the university or medical school,∗

public hospital that is founded by the government, such as national8 or city hospital,∗

private hospital that is established by the private organization or medical doctor.
The research question of the current study is what is the possible determinant of commitment of the

medical professionals who have peculiar characteristics, in order to utilize it in human resource
management. It would be investigated with the aspect of hospital categories mentioned above.

I-4

Design of the study

In the process of identification of the factors that may impact the organizational commitment of
medical professionals, it has become clear that the medical professionals by themselves have different
styles in their commitment. Followed by the review of the previous studies in chapter II, a survey ofcommitment and self-actualization in medical professionals is conducted in chapter III to investigate
the answer for the research question above. Based of the analysis of the study, the theoreticalperspectives for the human resource management in medical professionals are discussed followed by
the historical and cultural studies in chapter IV. The main interest of the present study is to investigate
the possible determinants to satisfy the medical professionals in the different institution. In chapter V,
the implicative and theoretical conclusion is to be shown for its practical use in the human resource
management of medical professionals.

6

Hasenfield (1992)
The official name is Ministry of Education, Culture, Sports, Science and Technology.
8
These are generally founded by Ministry of Health, Labor and Welfare or other public organizations.
7

3

II.

Literature review for the previous studies

II-1

Human resource management in medical and health care service

Hospital management changes rapidly along with medical environments and has become a principal
issue. Many factors are involved, the recent needs to reform of medical service system and the medical
malpractices with keen interests of the people. Effective hospital management is facing at anotherproblem, as the government rush to meet the immediate demands of fast growing aged populations
who require huge medical and health care cost. Under those circumstances, hospitals now focused indecreased cost to improve profit and maintain their high quality of medical treatment. Nevertheless,hospital managers emphasize not only on the control of hospital costs but effective implementation ofhuman resources. Attitude influences the behaviors of staffs, which directly affect theirperformance. In medical organizations, staffs with low satisfaction are not able to make good
performance. Therefore, it is very important to control their satisfaction of the medical and health care
professionals with considering their motivation. Although hospitals are not considered to becommercial enterprises, formulation of the strategic goal under the powerful leadership is required tothe hospital management on the basis of the parent of the total management. Especially, deliberate
human resource strategies have become getting important in many companies, that is similar situation
in hospitals. Strategic human resource management of medical profession has now become the main
subject in hospital management.
Human resource management is recognized as the most important factor to be a more productive
and competitive medical institution in Japan. The rapid increase of medical staffs requires an effective
management of human resources. In consequence, hospitals are giving more attention to the planningand effective management of their human resources, as measured in terms of recruitment and selection,
training and development, motivation and reward, retention strategies, and compensation and benefit
plan design.
In the former period, most of the Japanese nurses lack a sense of professionalism with consideration4

of the low educational levels of the nurses9. Based on my experience, it is actually true and Japanesenurses might have been considered, as it were, the housewives of the hospital10. But the recent
progression as professionals, the roles of nurses have quite enlarged and become specific. To enhancesatisfaction in their roles, nurses express a desire for balance in their professional commitment andpersonal lives by themselves11. Besides, questionnaire survey performed in Australia in 1996 has
shown that professional satisfaction is the main reason for doctors staying in or leaving rural practice12.
It has demonstrated that most potentially solvable problems are overwork, forced deskilling andconflict with other healthcare professionals. Indeed, it is no good as a doctor, but doctor is also frail
human being, not almighty. Similarly, stress and bullying are commonly seen in doctors choosing
research project 13 . Thus, the most important aspect in human resource management in medical
professionals, their satisfaction as a professional seems to be a key factor, because a lot of time andefforts have been used to get their current position as professionals.

II-2

Resource-based view in human resource management

Resource-based view is the noteworthy aspect in human resource management in medical
professionals. In the late 1980s, the theories of human resource management has grown and broadened
as it focused on strategic and business concerns. Wernerfelt14 has presented the resources approach of
exposing a focus on the accumulated ability as a source for the sustainable competitive advantages,
especially, human resource is the most typical issue that draw the attention.
In reality, organizations including hospitals have been tried to utilize a variety of approaches inorder to distribute human capital15. In turns, hospitals often make and buy their human capitals. From
this viewpoint, the previous investigations have shown that how various combinations of employment
modes, for instance, internalization and externalization, lead to competitive advantage. Barney16 who

9Long (1984)
ibid
11
Thorpe and Loo (2003)
12
Kamien (1998)
13
Stebbing et al (2005)
14
Wernerfelt (1984)
15
Davis-Blake and Uzzi (1993)
16
Barney (1991)
10

5

have established the resource-based theory have advocated that the classification of the capitals
including human capital in addition to other capital or assets. The view of these theories17 is groundedon the fact that sustainable competitive advantages are due mainly to resources and capabilities.
Studies conducted at the University of Michigan have looked at whether human resource
organizations had been shifting to more strategic focus18. This tendency led to the organizational
capability19 become a primary issue of human resources organizations20 as it began to add value bybuilding a capacity for change, creating organization and increasing financial performance21. Ulrich
has established the famous conceptual framework about the role of human resources that adds value.
Since then, human resources in the most competitive businesses shift on both strategic and operational
human resource from the former style of operational and transactional issues. His conceptual
framework is based on two dimensions. The horizontal axis reflects the competing demands of future
strategic focus and present operational focus. The vertical axis reflects the conflicting demands createdby the activities, that one end represents a focus on people and a focus on process, in vise versa. From
the juxtaposition of these two dimensions, the four types of roles have been defined as strategic partner,change agent, administrative expert, and employee champion. Researchers in post-Ulrich era havebeen focused in the study of strategy and practice. Thus, the effective control system is needed toperform the better human resource management22.
To take a holistic view of human capitals, high commitment and high-involvement work systems
would be foster sustainable competitive advantage. In the next part, the organizational commitment of
medical professionals is to be discussed.

17

ibid; Grant (1991); Teece et al. (1997)
The general concept in the following discussion refer to human resource is well discussed in Lepak and Snell (1999).
Conceptual and theoretical framework for strategic human resource management is explained by Wright and MacMahan(1992).
19
The term of “capability” is the capacity for a set of resources to integratively perform a task or an activity. As a source ofcompetitive advantage, a capability has is not to be imitable. Continuous usage makes a capability become stronger and moredifficult for competitors to understand and imitate.
20
Ulrich and Lake (1990)
21
Ulrich (1996)
22
Schuler and MacMilan (1984)
18

6

II-3

Organizational commitment

Although there are various arguments and thoughts, approach to organizational commitment could
be summarized as two major theories23. The most thoroughly investigated classical approach is andcommitment is the perspective advanced by Mowday, Porter and Steers, who have made major
contributions to the study of organizational commitment24. They emphasize the employee’s affective
bond with the organization and their viewpoint25 is characterized as follows:∗a strong belief and acceptance of the organization’s goals and values∗

a willingness to exert considerable effort on behalf of the organization∗

a strong desire to maintain membership in the organization

Intensive researches as to organizational commitment have been well investigated in organizational
behavior and social psychology. The researchers in organizational behavior have been regarded it as
the process that a worker makes a goal for the organization and value inside. On the contrary, theresearchers in social psychology have been regarded it as the process that the past behavior ofindividuals restrains themselves in the organization 26 . Mowday and his colleagues have beensummarized these former approaches.
Following research utilizing this approach to organizational commitment has revealed an inverse
relationship between commitment and turnover intention27 as well as a positive relationship between
commitment and regular employee attendance28. In spite of these studies, commitment has historically
been found to exert little direct influence on actual performance for the work in itself. Decreased
turnover intention and consistent attendance are themselves critically important attitudes and actions in
professional organization29.
Similar approaches to organizational commitment have been assessed a variety of the organizational
culture seen within the organization. Gross and Etzioni 30 , have classified as three different

23

Tao (1998) has been advocated to two representative research groups; one is Mowday’s and the other is Meyer’s.
Mowday et al. (1982)
25
ibid, p27.
26
Tao op. cit.
27
Porter et al. (1974)
28
Steers (1977)
29
Mathieu and Zajac (1990)
30
Gross and Etzioni (1985)
24

7

organizational value orientation; have classified as three different organizational value orientation; (i)coercive organizations that uses physical threats, (ii) utilitarian organizations that use material rewards
such as salary increases, (iii) normative organizations that utilize symbolic rewards such as employee
recognition or access to special opportunities. The feeling of employee involvement, in other words,
job satisfaction could maintain a normative as opposed to a utilitarian value approach. In medical
professionals, this seems to be the most valuable as discussed in this study later.
The concept of commitment has expanded by Allen and Meyer31. In addition to an affective
component, they divided an overall attitudinal commitment into continuance and normative
commitment. To date, a lot of researches base on the Meyer’s approach have shown that the three
aspects of commitment is a useful and reliable tool for the structural measurement and understandingof the nature of professional commitment. The study of nurses and nursing students revealed factor
analytic evidence, suggesting that all three aspects of this approach yielded distinct factors for
professional as well as organizational commitment32.

II-4

Self-actualization and motivation theories

After the well-known psychologist, Abraham H. Maslow (born in New York in 1908; died in 1970),
has developed the concept of self-actualization, a lot of social scientists including the researchers ofbusiness administration follow his famous conceptual thinking of Hierarchy of Needs 33 , when
examining the forces that drive and organize behavior, including motivation of individuals. His way of
thinking called five-stage model includes:i.

Biological and Physiological needs: air, food, drink, shelter, warmth, sex, sleep, etc.

ii. Safety needs: protection from elements, security, order, law, limits, stability, etc.
iii. Belongingness and Love needs: work group, family, affection, relationships, etc.
iv. Esteem needs: self esteem, achievement, mastery, independence, status, dominance, prestige,
managerial responsibility, etc.

31

Allen and Meyer (1990)
Meyer et al. (1993)
33
Maslow (1970 second edition [1954 first edition]) has developed this concept to seven and eight later.
32

8

v. Self-actualization needs: realizing personal potential, self-fulfillment, seeking personal growthand peak experiences.
According to Maslow, deprivation motivation arises from pain and discomfort when one is deprivedof the basic elements that are crucial for physiological needs for survival. Growth motivation, which
doesn't repair deficits but expands horizons, becomes a significant motivator only when the lower
levels of basic needs are met. As the medical professionals are satisfied with the lower level needs,
they tend to be develop the higher level of needs: humanistic self-actualization or spiritualenlightenment, redefining priorities, boundaries, and commitments thinking of their primary task as
the bearers of meaning and significance. Except for the medical professional working in the battlefield,
safety and physiological needs are satisfied, therefore, the latter three of level 3 through level 5 are to
be thought to deal with. The current study would focus the latter three components to assess the
motivation, as well as commitment, of the medical professionals.
Following after Maslow, Frederick Herzberg (born in Lynn, Massachusetts, in 1923; died in 2000)
has advocated "Motivation-Hygiene Theory"34 identifying two classes of factors that are important tobehavior on the work:i.

Hygiene factors: policies, supervision, interpersonal relationship, working conditions, security,salary.

ii. Motivators: achievement, recognition, work itself, responsibility, advancement, growth.
Later, a behavioral researcher and psychologist David C. McClelland (born in Mt. Vernon, NY,
1917; died in 1998) proposes that three fundamental needs (the need for achievement, affiliation, andpower) act as powerful motivators existing in different balances35. The needs are classified as follows:i. Need for achievement: the desire to be successful and to excel. Strong need for feedback, senseof accomplishment and progress.

ii. Need for affiliation: the desire to maintain close interpersonal relationships and to be liked.
iii. Need for power: the desire to influence and make an impact. Strong need to lead and to increase
personal status and prestige.

34
35

Herzberg (1966)
McClelland (1975); McClelland and Burnham (1976)

9In his theory, an individual's specific needs are acquired over time. These needs are learned andsocially acquired are shaped by one's life experiences. This theory sometimes is referred to as the threeneeds theory or as the acquired (learned) needs theory.
Based on these established theories, many recent investigators have branched into different
motivational approaches. For example, Qubein36 believed that is no need to motivate the people, as
they are already motivated. Instead, to determine what the motivators are and use them to channel thestaff's energy to the right place is thought to be important. In his article of "Ten Principles of
Motivation", he notes that "...all people are motivated but that people do things for their own reasons,
not yours." In Kennedy's37 seven elements for motivation, he dealt with human wants. He mentioned
the sense of mission, compelling role, personal coaching, the probability of winning, professional
growth, financial incentives, and emotional connection. Thomas38 postulated that the nature of work
has changed. He advocates in his book that work does not just provide us with the means ofsubsistence; it also makes possible all the pleasures and achievements of civilization.
In order to understand the features of medical professionals and to establish the theoretical domain,
the conceptualization using three independent facets would be applied in the current study following
after the previous studies.

II-5

Fundamental values of medical professionals

The very nature and values of medical professionalism39 are originally based on the concept of“Adeptus Medicus”. 40 This Greek word means “adept in medicine”, that is, someone having
knowledge and skill as well as aptitude in medicine. In another word, this is a medical doctor as aprofessional who is dazzlingly skilled in medical sciences. The medical profession shares the role of36

Free articles by Nido R. Qubein (2002)
Kennedy (2001)
38
Thomas (2001)
39
In the present study, the definition of medical professionalism is employed from the most famous definition by Wynia(1999). Briefly, "Three core elements of professionalism each different in nature are necessary for it to work properly. First,
professionalism requires a moral commitment to the ethic of medical service which we will call devotion to medical service
and its values. This devotion leads naturally to a public, normative act: public profession of this ethic. Public profession of
the ethic serves both to maintain professional’s devotion to medical service and to assert its values in societal discussions.
These discussions lead naturally to engagement in a political process of negotiation, in which professionals advocate forhealth care values in the context of other important competing societal values. "40
A book written by Akutsu in 1995 has the same title of Medical Saint, “Adeptus Medicus.”
37

10

healer, which has roots extending back to Hippocrates. Under the ancient tenets of the HippocraticOath, physicians pledge to uphold the injunction “primum non noscerei”(first do no harm). This is anoath traditionally taken by physicians, in which certain ethical guidelines are laid out. For physicians,
nurses, and psychologists, ethical issues are often among the greatest challenges in practice. Long after
their training, students in training tend to remember and may even be influenced more by experiences
rather than factual knowledge, just like the author of this manuscript (viz. me) who have spent his halfof life.
To think about the fountainhead of medical professionalism, this oath is very important ethics for us,
medical professionals. The Hippocratic Oath has been updated in the Declaration of Geneva, which
has been adopted by the General Assembly of the World Medical Association at Geneva in 1948 andamended by the 22nd World Medical Assembly at Sydney in 1968. It is a declaration of physicians'
dedication to the humanitarian goals of medicine. As this is quite important concept to think thepeculiar professionalism in medical field, I would like to cite the quotable passage as follows41:
The Declaration of Geneva reads "At the time of being admitted as a member of the medical
profession:∗

I solemnly pledge myself to consecrate my life to the service of humanity;∗

I will give to my teachers the respect and gratitude which is their due;∗

I will practice my profession with conscience and dignity;∗

The health of my patient will be my first consideration;∗

I will respect the secrets which are confided in me, even after the patient has died;∗

I will maintain by all the means in my power, the honor and the noble traditions of the medical
profession;∗

My colleagues will be my sisters and brothers;∗

I will not permit considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, or social standing to intervene between
my duty and my patient;∗

I will maintain the utmost respect for human life from its beginning even under threat and I will
not use my medical knowledge contrary to the laws of humanity;∗

I make these promises solemnly, freely and upon my honor."

41

Williams (2005, p18)

11

Such views on medical professionalism are attracting a great deal of attention, both from doctors
and from the general public. It can be thought that there is clearly much overlap between ethics andprofessionalism, and anyone interested in medical ethics needs to be aware of developments inmedical professionalism42.
Recently, the European Federation of Internal Medicine, the ACP-ASIM Foundation43, and the
ABIM Foundation44 start together the Medical Professionalism Project (Philadelphia, PA, USA) inlate 1999. The three organizations designated members to enroll a set of principles that all medical
professionals can and should aspire after. In this project, the fundamental principles are defined as thefollowing three: principle of primacy of patients' welfare, principle of patients' autonomy, principle ofsocial justice.
As the first principle is based on a dedication to serving the interest of the patient, altruism45
contributes to the trust that is central to the physician–patient relationship. Therefore, it must not becompromised to market forces, societal pressures and administrative exigencies. Moreover, the thirdprinciple of social justice, similar to the lawyer, is the most important to understand the facets ofmedical professionals. It is defined that, “The medical profession must promote justice in thehealthcare system, including the fair distribution of healthcare resources. Physicians should work
actively to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic
status, ethnicity, religion, or any other social category.” This spirit is directly linked to the concept ofself-actualization that is shown in the forth section of the present chapter. Thus, medical professionals
are working not only for themselves, but they remain committed both to patients' welfare and to thebasic tenets of social justice46. This point of view is essential to understand their curious features, incontrast to other professional occupation.

42

This is also discussed in the web site of Ethics Unit, World Medical Association Foundation
American College of Physicians - American Society of Internal Medicine Foundation. Robert Copeland, Southern
Cardiopulmonary Associates, LaGrange, GA, USA; Risa Lavizzo-Mourey, Robert Wood Johnson Foundation, Princeton, NJ,
USA; and Walter McDonald, American College of Physicians-American Society of Internal Medicine, Philadelphia, PA,USA.
44
American Board of Internal Medicine. Project Chair is Dr. Troy Brennan, Brigham and Women’s Hospital, Boston, MA,
USA
45This concept is also important to think about the feature of medical professionalism, e.g. independency or cosmopolitan,that would be discussed later.
46
Medical Professionalism Project op. cit. pp263-264. This concept is described in the section of preamble.
43

12

In addition to the form of three fundamental principles, a set of definitive professional
responsibilities are also summarized as ten categories: commitment to professional competence;commitment to honesty with patients; commitment to patients' confidentiality; commitment tomaintaining appropriate relationships with patients; commitment to improving quality of care;
commitment to improving access to care; commitment to a just distribution of finite resources;
commitment to scientific knowledge; commitment to maintaining trust by managing conflicts ofinterest; commitment to professional responsibilities.
Among the above ten categories, there are two commitment to professionalism. In the first category,
it is advocated that “the Physicians must be committed to lifelong learning and be responsible formaintaining the medical knowledge and clinical and team skills necessary for the provision of qualitycare. More broadly, the profession as a whole must strive to see that all of its members are competentand must ensure that appropriate mechanisms are available for physicians to accomplish this goal.”
Additionally, in the last category, commitment to professional responsibilities is defined as; “Asmembers of a profession, physicians are expected to work collaboratively to maximize patients' care,be respectful of one another, and participate in the processes of self-regulation, including remediationand discipline of members who have failed to meet professional standards. The profession should also
define and organize the educational and standard-setting process for current and future members.
Physicians have both individual and collective obligations to participate in these processes. Theseobligations include engaging in internal assessment and accepting external scrutiny of all aspects of
their professional performance.” This attitude is quite implicative to think about the medical
professionalism that is reflected to the Hippocratic Oath as previously mentioned. Thus, the medical
professionals are claimed to affirm the active dedication to the principles of professionalism, which
entails not only their personal commitment to the welfare of their patients but also collective efforts toimprove the healthcare system for the welfare of society as a whole. Now, these action agenda for the13

profession of medicine that is universal in scope are made in the various medical societies, similar to
the guiding precepts of enterprises or visionaries of companies47.
As professionals, physicians should profess their values 48 . To be successful as professionals,
physicians should commit themselves to a program of life-long, self-directed learning, they must be
thoughtful, kind and sensitive, must avoid arrogance, dogmatism and negativisms, and be honest,
moral, tolerant, trustworthy and above all, humble and compassionate49. Without the internal rewards,
such as self-actualization and responsibility, neither the amount of pay nor social recognition cansuffice. In the next chapter, the important factors of commitment in medical professionals would be
investigated with survey study based on the roles of the classification of hospitals.

III.

Survey study of motivation and commitment in medical professionals

III-1

Conceptual framework of the study

The critical aspects of human resource management seem to be depended on category of thehospitals. Medical professionals working in the university hospitals are proud of involvement for the
innovation of medical sciences and advanced technology. The feeling of pride and self-confidence
seem to be contributed to their self-actualization. This Maslow’s highest needs are typically seen in theprofessionals. Medical professionals are not exception to this theory. Therefore, to assess theirmotivators seems to be essential for the human resource management. In his two-factor hygiene andmotivation theory, the former factor would be taking account for the current consideration, because
recent theory has shown that people are already motivated50. Especially, the medical professionals
might be already motivated, indeed, but the proper evaluation might be needed for them. Because
every medical professional carries medical professionalism of Hippocratic Oath unconsciously, esteemneeds should be also involved. The most required role of the private hospitals is to be friendly andconvenient to the common people to access. The of role of public hospitals is to distribute and sustain

47

The author takes the critical position toward the concept of “Built to Last: Successful Habits of Visionary Companies”
written by Collins and Porras (1994).
48
Wynia et al. (1999)49
Duff (2002)
50
Qubein op. cit.

14

medical standards in the applicable region, therefore, the staffs have strong organizational
commitment that is also related to esteem needs and hygiene factors.
Thinking over the facts above mentioned, it might be very important for the human resource
management of medical professionals to accumulate knowledge about their motivations, values, andcommitments, although we can learn a great deal from the existing body of research knowledge in thevarious fields. For that purpose, a study to measure the overall commitment in medical professionals isorganized based on the category of the hospitals. Main aim of this study is to conduct of the researchwith the setting of above viewpoints.

III-2

Definition of the model and rationale

Investigation for staff commitment including organizational commitment has emerged as apromising area of research within the study of organizational psychology51. At most, interest in thiskind of study of has replaced an earlier
Figure 1.

Triangular pyramid model

52

emphasis on job satisfaction . The latter
Self-actualization

construct was perceived as a logical correlate
to job performance, with a hypothesis beingthat job performance would increase as staffs
became more satisfied with their work 53 .
Nevertheless,

literature

reviews

Medical Professionals
Affective

have

consistently concluded that the relationship

Continuance

Organizational commitment

between job performance and job satisfaction
Normative

is not strong. Despite a lot of studies that haveattempted to address the question, researchers
have described the relationship between
performance and satisfaction as "illusive" 54.

The model to consider medical professionals is
expressed as triangular pyramid. Organizational
commitment consisted of three facets (Affective,
Continuance, Normative) are forming the base of the
pyramid. As self-actualization is important aspect tograsp the feature of medical professionals, it is put into
the apex.

51

This concept is referred to the Report of “Background to the Staff Commitment Research Project” by Research andStatistics Branch, Correctional Service of Canada, 1992.

15

Thus, the job satisfaction is not the issue to investigate here in this study. Instead, I would like to focus
on the commitment by itself, regardless of the work is fun or not.
As explained in the fifth section of chapter II, medical professionalism is strongly based on thespirit of public service. We cannot leave the person in trouble alone. Standing on the Hippocratic spiritof, there are some motivation factors rooted in the category of the institution. In the previous section, it
has shown that the correspondence of the organizational category to the commitment factors. However,
the relation is not one to one pairs, instead, includes every factor. Nevertheless, it has light and shadeof importance, weighing relative importance. Thus, it has been established that the triangular pyramid
model as shown in Figure 1. The features of medical professionals and the category of hospitals would
be considered using this conceptual model.

III-3

Hypotheses formation

Each category of the hospitals has a part that contains other factors as well. This is very implicativeand interpretative because of the following explanation. The medical professionals in university
hospitals might have much self-actualization and lesser in organizational commitment. The
professionals in private hospitals might have stronger organizational commitment, and that in public
hospitals might have both. Based on the above arguments, three hypotheses are set up as follows:#

Hypothesis 1:
The medical professionals in university hospitals would have strong self-actualization.

#

Hypothesis 2:
The medical professionals in public hospitals would have both strong organizational
commitment and self-actualization.

#

Hypothesis 3:
The medical professionals in private hospitals will have strong organizational commitment.

To test the conceptual framework and its derived hypotheses, a survey is to be conducted for the
medical professionals in each category of the hospital, using the scale to measure the organizational
commitment, motivation test for self-actualization.
52

Schneider (1985)
Schwab and Cummings (1970)54
Iaffaldano and Muchinsky (1985)
53

16

III-4

Data collection proceduresIII-4.1

Sample and procedure

Participation in this study was voluntary and anonymous. The participants are full time medical
professionals including doctors and nurses in the university hospital, public and private hospitals in
Hyogo and Shizuoka prefecture (N= 254). The principal investigators in each hospital asked to the
medical professionals to answer the semi-structured questionnaire as is shown below. The individual
data sheets were distributed and collected by my acquaintances and colleague doctors. The study was
performed in April 2005.

III-4.2
III-4.2.1

Measures and questionnaire design
Organizational Commitment Scales

The Organizational Commitment Questionnaire (OCQ) is a 15-item, 7-point Likert-type scale
developed by Mowday et al.55 to measure an employee's identification with and involvement in aparticular organization. Three aspects of involvement and belief are included: belief in and acceptanceof the organization's goals and values, willingness to exert considerable effort on behalf of theorganization, and desire to continue employment in the organization. Higher OCQ scores indicate
higher commitment levels. Previous estimates of internal consistency have ranged from 0.82 to 0.9356.
According to the line of the research of professional and organizational commitment using samplesof teachers conducted by LaMastro57, Organizational Commitment Scales (OCS) that is consisted ofMeyer and Allen’s58 and the famous OCQ by Mowday has been employed in the current study. Briefly,
affective commitment to the organization was measured using seven items from Meyer and Allen’saffective commitment scale59 and two items from the OCQ60. These items were selected because they
seem most clearly to approximate the feelings of liking for, pride in, and valuation of organizational
membership assumed to underlie the affective form of organizational commitment. The organizational
55

Mowdays et al. (1982) op. cit.
Hinds et al. (1998); Mowday et al. (1979)57
From the article entitled as “Commitment and perceived organizational support” written by Dr. Valerie LaMastro in
Department of Psychology, Rowan University.
58
Meyer and Allen (1984, 1988), Allen and Meyer (1990)
59
Meyer and Allen (1984) op. cit.
60
Mowdays et al. (1979) op. cit.; Porter et al (1974) op. cit.
56

17

forms of continuance commitment and normative commitment were measured using the continuanceand normative commitment scales developed by Meyer and Allen61. One can refer to Allen andMeyer62 for a full discussion of the development and factor analysis of the affective, continuance andnormative commitment scales. So as to pertain to professional rather than organizational membership,
the original three commitment scales were reworded by LaMastro. Here in the study, his way ofinvestigation using OCS is to be followed after. All scales utilized a 7-point Likert-type format(strongly disagree to strongly agree). Items from each of the scales are listed in Appendix A-1.

III-4.2.2

Short Index of Self-Actualization

The additional measure to test their self-actualizing tendency was the Short Index of
Self-Actualization (SISA), which is a widely used questionnaire with well-established reliability andvalidity developed by Jones and Crandell63. The SISA uses 15 items to which the subject must stateagreement on a 7-point Likert scale (strongly disagree to strongly agree).
Maslow’s ideas have resulted in attempts to measure self-actualization through self-report. The
most widely used of these measures is Personal Orientation Inventory (POI) 64 , a 150-item
forced-choice inventory that is difficult to fake. Because the POI is fairly lengthy, SISA is used as aneasy scale to measure self-actualization that is much shorter but possesses adequate reliability andvalidity. Among the two tests developed which attempt to tap Maslow’s conception of self-actualized
people, the simple SISA is integrated into the present study. Items of SISA would be listed inAppendix A-2.

III-4.2.3

Japanese form of for the individual data sheet

To apply these established scales into the current analysis, I have translated them into Japanese
language and reformed suitable to survey for the medical professional in the hospitals. It is consistedof from four parts. The first three parts (Part A to C) are from OCS. Those are set in the beginning,
61

Meyer and Allen (1988) op. cit.
Allen and Meyer (1990) op. cit.
63
Jones and Crandell (1986)
64
Shostrom (1964)
62

18

because commitment questions are easy to answer, followed by the questions for self-actualization(SISA).
Part A: affective organizational commitment-----

9 questions

Part B: continuance organizational commitment-----

7 questions

Part C: normative organizational commitment-----

6 questions

Sub-total -----

22 questions-----

15 questions-----

37 questions

Part D: Short Index of Self-Actualization
Total

Odd-number questions are printed in black and even-number questions are printed in gray as avisual effect to avoid mistakes. The scale point of the center (neither disagree nor agree) is adjusted tobeing labeled as zero to avoid mistake marking. The scale point anchors labeled as (-3) strongly
disagree (-2) moderately agree (-1) slightly disagree (0) neither disagree nor agree (1) slightly agree:(2) moderately agree: (3) strongly agree. Approximately, it takes five to ten minutes to answer all ofthe questions.

III-5
III-5.1

Data analysis
Procedures and data distribution

The evaluation version release 13.0 of the Statistical Package for the Social Sciences (SPSS for
Windows, 2004, SPSS, Inc.) and student version release 11.0J (SPSS, 2003) were used for thestatistical analyses. Continuous variables were entered into the computer as they had been responded
to on the questionnaire. As to the category of profession, the majority are medical doctors and nurses,
therefore, other professions are categorized as others. Categorical variables such as hospital (1 =University Hospital, 2 = Public Hospital, 3 = Private Hospital) and profession (1 = Doctor, 2 = Nurse,
3 = Others) were coded before they were entered into the computer. The cross-tabulation of thesamples are shown in Appendix B-1.

III-5.2

Descriptive statistics and correlation

19

The descriptive statistics of whole samples is shown in Appendix B-2. During the process ofchecking the distribution of the data, outliers that were far apart from the main distribution wereidentified, as seen in Appendix B-3 and B-4. Therefore, data over the three times of standard deviation(±3SD) were defined as outliers, exempted in the later analyses.
The descriptive statistics including sample number, the mean and standard deviation of eachcategory are shown in Appendix B-5. Organizational commitment among doctors, as well as nurses
showed low in university hospital and increased in public and more in private hospital. Looking at thecomponents of organizational commitment, affective commitment is similar result in nurses. Butinterestingly, doctors have strong affective commitment in university hospital and the tendency isreversed among them. Doctors in private hospital and nurses in public hospital showed highcontinuance commitment. Normative commitment is parallel with organizational commitment.
Therefore, in university hospital, doctors have strong affective commitment in spite that their total
value of organizational commitment is low. But nurses in university hospital show low affective
commitment but high in nurses in private. This results indicates that the category of hospital isimportant for the medical professionals and the different tendency is to be identified between theprofession of doctors and nurses.
Self-actualization among doctors is generally high in all classification of hospitals, although thatamong nurses is gradually decreased from university hospital to private hospital. These results might
be related to that doctors are circulating between university hospital, public and private hospitals ingeneral.
Prior to analysis, correlation matrix of Pearson correlation coefficients was constructed (seeAppendix B-6). In the nature of things, organizational commitment and their components (affective,
continuance, normative) have shown significant correlations (p<0.01). Especially, Strong positive
correlations 65 were identified between organizational commitment and “affective” as well as“normative” (r = 0.759, 0.831, respectively). Relatively strong positive correlations were also65

In the present study, correlation coefficients over 0.70 is regarded as strong; 0.40 to 0.70 as relatively strong; 0.20 to 0.40
as weak; less than 0.20 as little correlation.

20

identified between the variables “affective” and “normative” (r = 0.485). Meanwhile, “continuance”
showed weak correlation to other factors.

III-5.3

Analysis of variance and multiple comparison

As seen in Appendix B-7, all variables have shown to be significant in analysis of variance with
controlling for the category of hospital.
Organizational commitment:

F (2, 248) =38.224p<0.01Affective commitment:

F (2, 248) =9.131

p<0.01

Continuance commitment:

F (2, 248) =10.834p<0.01

Normative commitment:

F (2, 248) =33.259p<0.01

Self-actualization:

F (2, 250) =5.435

p<0.01

Then, multiple comparison using Tukey honestly significant difference has been conducted (Appendix
B-8).

In organizational commitment, all categories of the hospitals showed significant differenceseach other. As to affective commitment, private hospital showed the significant differences to others,
but there is no difference between university hospital and public hospital. Therefore, we can say that

Figure 2.

Summary of multiple comparison in the categories of hospitals

OC

AC

Pri

Pri

CC
Pub

Pri

NC

SA

Pri

Univ

High

Pub
Pub

Univ

Pub

Univ

Pri

Pub
Univ

Univ

Low

Arrow indicates the significant correlation (p<0.01). Correlation with not significant showed just the position
with no arrow. Univ: University hospital, Pub: Public hospital, Pri: Private hospital. OC: organizational
commitment, AC: affective commitment, CC: continuance commitment, NC: normative commitment, SA:
self-actualization.

21

affective commitment is strong in private hospital. Similarly, continuance commitment is weak inuniversity hospital, and normative commitment is stronger in public and strongest in private. As theresult, the total organizational commitment is significantly strong in private hospital and weak inuniversity hospital over all. Self-actualization is significantly strong in university hospital compared to
private hospital but not significant to public. The relation between the categories of hospitals issummarized in Figure 2.

III-5.4

Two-sample t-test

Because the sample number in profession category of others is limited (N = 21), two-sample t-test
has been performed, comparing the two major populations of the profession, doctors and nurses. The
detailed is listed in Appendix B-9.
Organizational commitment:t (228)= 0.059

n.s. (not significant)Affective commitment:t (62.32) = 1.952

n.s.

Continuance commitment:t (228)= 5.374

p<0.01

Normative commitment:t (228)= 1.086n.s.

Self-actualization:t (230)= 2.845p<0.001

Thus, in the aspect of the profession, there are significant differences between doctors and nurses incontinuance commitment and self-actualization. Thinking together with Appendix B-9A, medical
doctors have a tendency of stronger self-actualization and less continuance commitment than nurses.

III-5.5

Multiple linear regression analysis

Multiple regression analyses were conducted to determine the relationship between the independent
variables of hospital and profession and the each dependent variable of organizational commitment(including affective, continuance and normative) and self-actualization. The results of each multiple
regression analysis are summarized in Appendix B-10. The results are to be evaluated in the following
section using path diagram.

22

III-5.6

Path analysis of commitment in medical professionals

III-5.6.1

Correlation within the commitment components

Path analysis, originally developed by Sewall Wright, depicts a mathematical model that is
hypothesized to explain the correlations among variables. It has since been adopted by virtually all the
behavioral sciences and applied to a large number of studies in social sciences. In the beginning, thecorrelation between the each commitment has been rearranged as is shown in Figure 3. As thecomponents for organizational commitment, both affective commitment and normative commitment
have deep contribution (r = 0.759, 0.831, respectively). Continuance commitment has weak positive
correlation with organizational commitment (r = 0.291). Affective commitment showed relatively
strong correlations with normative commitment (r = 0.472) and weak negative correlations with
continuance commitment (r = -0.219).

Figure 3.

Path analysis of correlation in three components of commitment

Affective

0.759*

Normative

0.831*

OC
0.069 n.s.

- 0.219*

0.291*
Continuance

Asterisk indicates significant at the 0.01 level of confidence. The width of the arrow means
the degree of correlation: strong (broad), relatively strong (middle), weak (narrow) and nocorrelation (broken line). OC: organizational commitment.

III-5.6.2

Multivariate regression analysis

To investigate the relation of multiple predictors (hospital and profession) and commitment factors,
multivariate regression analysis was conducted followed by multiple linear regression analyses
performed for each depable of commitment components. Multivariate regression analysis revealed apositive influence of the category of hospital with respect to organizational commitment (β = 0.494),
while profession did not (β = -0.041, n.s.). Concerning the components of organizational commitments,

23the category of hospital shows positive effects on all three components of commitments (affective, β =0.266; continuance, β = 0.221; normative, β = 0.477), while profession did not (affective, β = -0.048,
n.s.; continuance, β = 0.082, n.s.; normative, β = -0.085, n.s.). Nevertheless, considering selfactualization, both the category of hospital and profession revealed little effects, indicating that selfactualization is to be independent to these two predictors (β = -0.157, β = -0.165, respectively). For
systematic consideration of the results, path diagram applied to the triangular pyramid model has been
constructed with two predictors of the categories of hospital and profession (Figure 4).

Figure 4.

Path diagram applied to Triangular pyramid model(A) Organizational commitment and Self-actualization
Self-actualization- 0.165**- 0.157**
Hospital

0.494**

Profession- 0.041 n.s.

Organizational commitment(B) Three components of organizational commitment
Hospital

Profession- 0.085 n.s.

0.266**- 0.048 n.s.
Affective

0.477**

Normative

0.082 n.s.

0.221**

Continuance
Statistical significance indicates as solid lines (** p<0.01) and not significant (n.s.)
as broken lines.

24III-5.7

Findings of the analyses

As independent variables, categorical variables of hospital, categorizing as University Hospital = 1,
Public Hospital = 2, Private Hospital = 3, and their profession, as Doctor =1, Nurse = 2, Others = 3,
were defined to see the relation with the dependent variables of organizational commitment, and its
components, affective commitment, continuance commitment, normative commitment and selfactualization.
Descriptive statistics implicates that organizational commitment is stronger in private hospital andlow level of continuance commitment and high self-actualization have been identified in university
hospital. As for the profession, affective commitment is strong in nurses and weak in doctors, and thistendency is more obvious in private hospital.
In the analysis of variance, all dependent variables have shown to be significant with controlling forthe category of hospital. Multiple comparison has conducted to investigate the difference between the
categories of hospital. Private hospital showed significantly strong organizational commitment thanpublic hospital that is also significantly strong than university hospital. As to affective commitment,
private hospital showed the significantly high to other two categories of hospital. Meanwhile,
continuance commitment is significantly weaker than other two. In public hospital, normative
commitment is significantly stronger than university hospital and significantly weaker than private
hospital. The difference of self-actualization is significant in university hospital and private hospital.
In the aspect of profession, the difference in doctor and nurse has been investigated because thetotal number of others is relatively small in the category of profession. Two-sample t-test was
conducted to compare doctor and nurse, revealing that doctors are significantly low continuancecommitment and strong self-actualization than nurses.
To consider the all two predictors of hospital and profession simultaneously, multiple linear
regression analysis was conducted. Using path analysis, multivariate regression analysis was
conducted followed by multiple linear regression analyses performed for each dependent variable ofcommitment components to determine the relationship with dependent variables of organizational
commitment and its three components and self-actualization. It showed that a positive influence of the25

category of hospital with respect to organizational commitment, while profession did not. Concerning
the components of organizational commitments, the category of hospital shows positive effects on all
three components of commitments, while profession did not. Both the category of hospital andprofession revealed little effects on self-actualization, indicating that self-actualization is independent
to these two predictors.
In path analysis, the triangular pyramid model with the plane base of organizational commitment(affective, continuance, normative) and apex of self-actualization.

III-6

Verification of hypothesis

In the present section, the hypotheses set up in chapter III-3 is verified based on the results ofsurvey study.
#

Hypothesis 1: The medical professionals in university hospitals would have strong selfactualization. Partially approved. The difference of self-actualization is significant in university
hospital and private hospital in multiple comparison. The medical professionals in university
hospitals are not significantly stronger than that in public hospital.

#

Hypothesis 2: The medical professionals in public hospitals would have both strong organizational
commitment and self-actualization. Totally refuted.

#

Hypothesis 3: The medical professionals in private hospitals will have strong organizational
commitment. Approved. Private hospital showed significantly strong organizational commitment
than public hospital and university hospital in analysis of variance.

III-7

Practical implications and limitations

The following is a discussion of how findings from the present survey study could be considered by
the human resource manager in hospitals to enhance the medical professionals.
First, the relationship between organizational commitment and characteristics in category of
hospital is investigated. As shown in Figure 4B using the triangular pyramid model, results from thisstudy indicates that the category of hospital strongly affect all the components of organizational26

commitment. Little continuance commitment among doctors might be related that they can open clinic.
As nurses cannot become independent, they show strong commitment in the private hospitals.
Next, self-actualization is commonly high in medical professionals, with no involvement of thehospital category and profession. Although the profession has not significant importance of therelationship between organizational commitment and its components, it has significantly shown thatno relation with self-actualization as the same as category of the hospital. This is a very interestingfinding because the profession they choose is already the consequence of self-actualization, with higheducation and national license, after the long competition and keen selection. Thus, there is acharacteristic features in medical professions, called medical professionalism. In order to manage them,
it is inevitably necessary to understand this feature.
As to the limitations of the study, it might be controversial that the generalization using the samples
of Hyogo prefecture (most of the hospitals) and Shizuoka (one hospital). Besides, the factor of age
might be another important factor. In general, young nurses and doctors are common in university
hospital compared to other category of hospital due to the hard work in advanced medication.
Meanwhile, the age of the nurses in private hospitals varies. In the future study, the factor of age is to
be involved for this kind of study.
Nevertheless, we can say that the classification of hospital is more important factor than profession
overall in spite that there is significantly no relation with self-actualization. In the next chapter, thischaracteristic feature would be discussed from the perspective of medical professionalism, collatingwith the literature review in chapter II-5.

IV.

Theoretical perspectives of medical professionalism

As is shown in the previous chapter, self-actualization is strong in medical professionals regardlessthe category of the hospital and the profession. The professional education and the following
professional training might breed this feature in medical professionals. The professional culture, thatenhances strong self-actualization, is another important facets in medical professionals, commonly
existed regardless of the organization. In the current chapter, the reason why the independency of27

self-actualization is fostered would be attempted with understanding the background of medical
professionalism. After the historical and cultural consideration, the actual facets of medical
professionalism are to be investigated, having interviews with two representative medical
professionals, a doctor and a nurse.

IV-1
IV-1.1

Historical cultivation of medical professionalism
History of medicine

The Greeks were practicing medicine 1000 years before the birth of Christ. In the ‘Iliad’ by Homer,
injured soldiers were treated by doctors and the Greek leader in the tale, Menelaus, was treated for anarrow wound by a doctor-in-arms, Machaon. However, not all Ancient Greeks turned to physicians
when ill, many still turned to the gods. The god Apollo was consulted at a temple in Delphi and by thesixth century B.C., many turned to Æsclepius66, Greek god of healing and the son of Apollo, for help.
Places called asclepeia were built for those in poor health, presumably old style of hospitals. These
were like temples and here people came to bathe, sleep and meditate. The poor were also allowed tobeg for money in these buildings.
Æsculapius, had many followers who used massage and exercise to treat patients. This god is also
believed to have used the magical powers of a yellow, nonpoisonous serpent to lick the wounds ofsurgical patients. Æsculapius was often pictured holding the snake wrapped around his staff; this staff
is now a symbol of medicine. Another medical symbol is the caduceus, the staff of the Roman god
Mercury, shown as a winged staff with two serpents wrapped around it. When I have worked as a
research fellow in Harvard Medical School in Boston, I often seen this symbol of caduceus andunderstand its meaning. Logo of Medical School in Kobe University also expresses the meaning of
caduceus, forming the capital of “K” with a snake and pen (Figure 5).
This might be a certain kind of cultural effect from Greek though Western civilization. Around 400
B.C., Hippocrates (circa 460–380 B.C.) practiced medicine and set high behavioral standards forpracticing physicians. He is called as the “Father of Medicine” and turned medicine into a science and66

According to my knowledge obtained from the book read before, he was a man of doctor and later become God because of
his excellent medical skills by the people.

28

erased the element of mysticism that it once

Figure 5.

held. He wrote the famous Hippocratic Oath,(A)

Medical symbol of Caduceus
(B)

(C)

which is still part of medical school graduation
ceremonies and in some hospitals.
In Greco-Roman period, the doctors arethought to be holly saints. They might nothaveaspecialcommonfeelingasprofessionals. Following the Dark Ages and(A) Original Staff of Æsculapius (B) Medical symbolof caduceus with staff of wing and snake. (C) Logo of
medical school of Kobe University. Pen and snake
form a letter “K”, an initial of Kobe, put in the center oflife saving float indicating that the marine city of Kobe.

Middle Ages, the Renaissance was a period ofenlightenment in all areas of art, science, andeducation, and it fostered great advances in medicine. Italy was a center of medical science in this era.
The advent of the printing press and the establishment of great universities made the practice of
medicine more accessible to larger numbers of practitioners. Great minds collaborated to advance
medical and scientific theories and perform experiments that led to discoveries of enormous benefit in
the fight against disease. Thanks to the following advances in medical sciences, the awareness of
medical professionalism is to be formed among the professionals, which would be linked
self-actualization as seen today.
After Genpaku Sugita, the modern Japanese medicine has been started under the influence ofEuropean medicine (switched to German in Meiji era) and then American medicine after the WorldWar II. The medical professionalism in Japan has been developed after the war, with established social
status. Therefore, to think about the medical professionalism, the origin of medical professionalism inWestern medicine would be discussed in the next section, with the historical perspective of the
Hippocratic Oath, called “Father of medicine”

IV-1. 2Formation of medical professionals

In the aspect of human resource management, this progress in medicine brought an increased
population of medical staffs. Not only the total population, but the variety of allied health care29

professionals is also increased in addition to doctors and nurses, listed as follows: chiropractor,
dietitian, electrocardiograph technician, electroencephalograph technician, emergency medical
technician, histologist, infection control officer, laboratory technician, medical assistant, medical
coder, medical office assistant, medical transcriptionist, nuclear medical technician, occupational
therapist, paramedic, pharmacist, phlebotomist, physical therapist, psychologist, radiographer,
respiratory therapist, risk manager, social worker, speech therapist, unit clerk.
Still in Japan, the allied professionals are not so much classified as in Unites States listed above. Butsoon after, it would be differentiated just as this two decades that I have been watching the process as adoctor. Meanwhile, it is needed to have some kind of ideology to regulate these tremendous medical
professionals. Similar to the Declaration of Geneva introduced in Chapter II-5, a lot of carters are now
made by many medical organizations and institutions. The reason might be related to the establishmentof medical professionalism.
As seen in historical view of development in medicine, it gradually formed the stereotypes for the
medical professionals. For the doctors, Hippocrates of Cos has become a model of medical ethics as
and Florence Nightingale for the nurses as professionals. Thinking the difference between these twomodels, we can notify the interesting issue. That is, with the comparative aspect, the model for the
doctors is a medical saint and that for nurses is a voluntary servant. This presumably support thecurrent result of survey study that doctors and nurses have different degree in self-actualization.

IV-2
IV-2.1

Hippocratic Oath and medical professionalism
Hippocratic Oath in medical history

There is an evidence of the use of the Hippocratic Oath from its creation through the eighteenth
century, though there is not extensive documentation of variations on the Oath. It is thought by somescholars that Galen, who lived at the end of the second century, brought Hippocrates’ work tocompletion.67 There is also testimony that throughout the early Middle Ages there was mention of

67

Dorman (1995)

30

medical oaths.68 Several ninth century manuscripts from Paris and Charters remind physicians to abideby the Hippocratic Oath. In the tenth and eleventh centuries, which saw the Christian oath take form,
there are also manuscripts in Copenhagen pointing to the use of the Hippocratic Oath.69 The twelfth
century saw the creation of the Oath of Maimonides. “With the advent of the universities during the
Middle Ages the Oath became a part of the curriculum of medical students. Since incorporation into
the rituals of universities… oaths have never fallen into disuse.”70 The first printing of the Oathoccurred in Verona in the late fifteenth century. Subsequently, it was frequently printed in Elizabethan
England, together with interpretations. To supplement the personal oath, several codes outlining
standards of conduct within medical institutions were developed in Europe in the eighteenth century,
when there was a growth in the number of physicians and hospitals.71
In the early nineteenth century, there increased interest in the ethics of the medical profession
expanding on the Hippocratic Oath. In 1803, Thomas Percival, a British physician, published “Medical
Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians andSurgeons.”72 This book has outlined an ethics for the medical community and prescribing a set ofduties and responsibilities for the individual doctor.73
In the early 1800’s, there found a lot of medical professionals in the United States, including
midwives, homeopaths, hydropaths, botanic healers, Indian healers, and also quacks. All of themoffered their own services to the sick, but often of dubious benefit. Even among physicians there was awide range of ability since there was a general lack of scientific knowledge. It was at this time inhistory, when doctors felt threatened by other “practitioners,” when an overwhelming public distrust
existed, and when conflict among even the allopathic physicians themselves occurred that American
doctors organized into the American Medical Association (AMA) and adopted a professional code of
ethics, expanding on the Hippocratic Oath. Dale Smith74 conveys well what took place during thistime: He wrote in his book, “The medical profession of the mid-nineteenth century was under assault
68

Crawshaw (1970)
Macer (1990)
70
Crawshaw op.cit.
71
Macer op.cit.
72
Percival (1803)
73
Furst (2000)
74
He is a professor of department of medical history in Uniformed Services University of the Health Sciences69

31

by various social forces, and the AMA, its code of ethics, and perhaps the use of the Hippocratic Oath
all served as tools for the defense of the profession.”75
In the context of the necessity of the Hippocratic Oath, this consideration might hit the mark. Afterlicensing and proper professional regulation were introduced in the 1870’s and 1880’s, the newly
acquired scientific knowledge and other medical contributions slowly improved the public image ofthe medical profession.76 During this growth of confidence, with the positive public sentiment of the
medical field before the beginning of the 1900’s, it seemed as though there was no need for
Hippocrates.
However, the medical profession returned to the Hippocratic tradition in the twentieth century.
There has been a steady increase in the use of some form of the Hippocratic Oath in the US medical
school. In 1928, 19% of graduating medical students took the Hippocratic Oath, in 1959, 74% becauseof post World War II, in 1969, 92% with high jumping, in 1977, 94%, in 1993, 100% of medical
schools in the United States administered the Oath at graduation.77
Unfortunately, the Hippocratic Oath is not so much popular in Japan as in the United States. I
myself, has not been learned in medial school but studied after the graduation with some medical
journals. Although the above numbers illustrate an increase of usage, it does not explain the reason
why there was such an increase in the use of the Hippocratic Oath in the twentieth century.

IV-2.2

Request of Hippocratic Oath in medical professionals

As a background, it might correlate to some historical and social changes over the medical
professionals. There could be summarized as two major reasons. One is related to a terrible humantragedy of the genocide that occurred in Nazi Germany. The Nuremberg Code was not the only
document to be written in response to the medical atrocities committed during the Nazi regime. “Thekey contribution of Nuremberg was to merge both Hippocratic ethics and the protection of human75

Smith (1996)
obid.
77
Orr et al. (1997)76

32

rights into a single code.”78 Thus, as shown in chapter II-5, the General Assembly of the World
Medical Association adopted the Declaration of Geneva, which is another revision of the Hippocratic
Oath. This declaration was a pledge to have the greatest respect for human life and not to use medical
knowledge contrary to the laws of humanity. The word of “Humanity” is a very important tounderstand the medical professionalism. As for the nurses, Nightingale is also a symbolic model ofhumanity although there is some image of dedicative servant.
The other is the social request of a release of medical information, that is, “informed consent,”
which included patients in the decision-making process. Beginning in the 1960’s, there was a generalchallenge to all established authority by mass media. Thus, the relationship between doctor and patient,
as well as between medicine and society, has been altered. I have been thinking that this change ofmind (so-called sense of values) would be deeply based on the Vietnam War (1961-1975). In Japan, it
was brisk in student movements at that time.
The 1960’s through 1970’s were the times of cultural struggle with instability. The civil rights
movement79 including the women’s rights movement, and the patient’s rights movement, all threatened
established society and medical society was not the exception to this cultural changes. The powerfulscientific and socially established medical authority had been broken again as the same as the critical
period of 1800s. Under such a circumstances, a certain kind of core principle for the doctors might beneeded to maintain their dignity. Making ironical remarks, the Hippocratic Oath saved the doctors
again.
The development of medical ethics in 1971 illustrates an intense acknowledgement of the ideals of
Hippocrates. However, as the times were changing in the medical profession, a change in the
Hippocratic ideal was needed. The major historical and societal changes would affect the revision of
the Hippocratic ideal. These alterations and modifications can be explained by understanding thehistorical context. When there was self-confidence among the medical profession, the Hippocratic
Oath would not be needed, but as social unrest reached to them, it is required that the use of the
Hippocratic ideal for the medical professionals.
78
79

Schuster (1998)
Martin Luther King was shot dead in 1968.

33

As for the nurse, there is the Florence Nightingale Pledge that is most often recited at
graduation/pinning ceremonies for nurses. This is a modified version of Hippocratic Oath, which wascomposed in 1893 by Mrs. Lystra E. Gretter and a Committee for the Farrand Training School for
Nurses, Detroit, Michigan. It was named the Florence Nightingale Pledge in honor of the esteemedfounder of modern nursing. The Pledge imprecates allegiance as well as the spirit of medical
professionalism. For instance, there is a description in the pledge of the virtue to maintain and elevatethe standard of profession.
We can see the essential of medical professionalism in both the Hippocratic Oath and the FlorenceNightingale Pledge. During the medical education as professionals, we are unconsciously learned suchan attitude of medical professionalism.

IV-3

Insights through historical and cultural approach

In the current section, the brief medical history and the realization of medical professionalism havebeen thought by historical and cultural studies, using the aspect of Hippocratic Oath and the FlorenceNightingale

Pledge.

Thinking

about

its
Figure 6.

Role of medical professionalism

application to medical professionals, the social
Self-actualization

background and the historical points of vieware inevitably necessary for the profoundunderstanding of medical professionalism. In

Medical Professionals

general, ethic and visionary ideals are requiredat the time of crisis for the professionals. As
Culturethe result, the professionals could keep theirSocial request

Historical view

dignity and that would be contributed to

The triangular pyramid model has applied to consider
medical professionalism. Medical professionals areaffected with its background of three facets (culture,
historical view, and social request), forming medical
professionalism among them, and contribute tocomposing self-actualization, as is shown at the
apex.

maintain the self-actualization. In Japan, moral
and discipline are now claimed to us, medical
professionals. Soon in medical schools, ethics

34

such as Hippocratic Oath would be used during the process of the education as in U.S. The feature ofself-actualization is to be based on this medical professionalism. This might be the reason of thecurrent result in survey study that self-actualization is high with no involvement of the hospital
category and the kind of profession. The relationship of these aspects is summarized using triangularpyramid model in Figure 6.

IV-4

Theoretical perspectives

As seen above discussion, education is the critical issue to foster the medical professionalism.
Indeed we studied huge medical and scientific knowledge in medical school and attitude for thepatients, but we have learned a lot of things through the senior doctors and other medical professionals.
Most of them are, as it were, “hidden curriculum.” Dr. Thomas S. Inui writes in his free paper80 that,“Since a shift in culture is required to substantially affect education for professionalism in medicine,then no stakeholder in the community of medicine can be uninvolved in the change.” He also
continues that, “the present intensity of our discourse about professionalism in medicine represents
both a flight from commercialism, on the one hand, and a corresponding need to reaffirm our deeper
values and reclaim our authenticity as trusted healers, on the other.” This point of view is quite
important for embedding professionalism in medical education.
Meanwhile, Eliot Freidson81 wrote in his book entitled as Professionalism: The Third Logic, that,“The functional value of a body of specialized knowledge and skill is less central to the professional
ideology than its attachment to a ―transcendent value that gives it meaning…”
Thinking together, we have to realize that public and personal trust in the medical professionals is anecessary before caring and healing. In another word, those are responsibility and duty that is written
in Hippocratic Oath. Nevertheless, based on the results of the survey study indicate that low level ofnormative commitment in doctors and nurses, especially in those in university and public hospitals.
But first of all, we have to define the professionalism clearly. Otherwise, we will loose the public trust,
80

Inui T.S. (2003) A Flag in the Wind: Educating for professionalism in Medicine, Association of American Medical
Colleges.

81

Freidson (2001)

35

Figure 7.

Role of medical professionalism for the culture management

Management System

Medical Professionalism
Doctors

NursesOther professionals

Sub-culture

Sub-culture

Sub-culture

the most precious treasure as a professional. In the famous classic play of “The Doctor’s Dilemma,”
George Bernard Shaw82 wrote with a cynical words that, “All professions are conspiracies against thelaity.”
In general, the organizational commitment is rather low in medical professionals overall, there is aneed to manage them as a concept of human resource management. The proper culture of medical
professionalism, as well as ethics, might be essential for the human resource management. As shownin Chapter I-2, there are sub-cultures among the medical professionals. But with utilization of medical
professionalism, those would be unified under the splendid management. The conceptual schema isshown in Figure 7.
As for the management of organizational commitment, the current study indicates that the categoryof hospital is a significant issue. Thus, the difference of hospital should be taken into account. High
self-actualization, the characteristic feature of medical professionals (especially in doctors), is mainly
related to the medical professionalism. But as discussed in the current chapter, it might be thoughtwith historical view and social request as well as the culture in hospitals.
Medical professionals are blessed with the opportunity of job-change, so called turnover. Therefore,
the essential point of issue for the human resource management is to regulate them through medical
professionalism. As seen the interviewee 1, to respect for their professional ability might be a key to82

The Doctor’s Dilemma was first staged in 1906. Shaw is the only person ever to have won both a Nobel Prize (Literature in
1925) and an Academy Award (Best Screenplay for Pygmalion in 1938).

36

increase the organizational commitment. As a lot of officers in the hospitals say unanimously, humanresource management of medical professionals are rather difficult compared to another field becauseof the less commitment and easy access to turnover. The most important point would be proper
evaluation and recognition as professionals, respecting their medical accountability.
The traditional theory of medical accountability is rooted in a professional model where health care
is not a commodity, but a service.83 Therefore, authority and accountability are two sides of the
medical professionalism. Medical professionals are accountable to the patient and also to their
specialty. Although physicians are granted privileges by society, it is the medical profession itself that
determines authority. Professional authority, in fact, is required for the successful practice of medicine.
Medical professionals are charged to make correct medical decisions for the proper reasons, as they
are granted the authority to do so.
Talcott Parsons constructed the first theoretical concept directly applicable to medical sociology, byutilizing the parameters of classical sociological theory, such as Max Weber’s work. In Parsons' view,society worked best when each individual unit was fully functional. Because of the esoteric nature of
the knowledge base in medicine, society was content to give the profession a self-regulating status that
had high social and financial value for physicians. This concept might explain that medical
professionalism contributes to form self-actualization within medical professionals.

V.

Concluding remarks
In the current study, it has been investigated to understand medical professionals using various

approaches, in order to contribute to their human resource management, which is hard to deal with.
The findings with the survey study are quite important in the human resource management for medical
professionals who can easily move to the new positions. The executive managers in the hospital haveto recognize this fact to manage and satisfy their needs. Next, different from organizational
commitment, medical professionals have high self-actualization regardless to the category of thehospitals. Thus, it has been shown with historical and cultural studies to investigate the reason of their

83

Parsons (1951)37

high self-actualization, found that this characteristic feature of medical professionals is related to theeducation and crisis of the society. These results would provide the potential insights to understand thekeys in the human resource management for medical professionals.
In addition to these meaningful findings, the importance of this study is to provide the viewpoints tounderstand medial professionals with two axes. One is organizational commitment consisted of threecomponents, the other is self-actualization reflecting the medical professionalism. To make it easy to
grasp the relationship between these factors, the triangular pyramid model has been considered,forming a base with organizational commitment (affective, continuance and normative) and an apex
with self-actualization. Similarly, to understand the background of self-actualization, the triangularpyramid model has been applied forming a base of medical professionalism with culture, historicalview and social request. This way of thinking is useful to understand the features of medical
professionals. Thus, the current results and the triangular pyramid model would render the criticalaspect to human resource management for medical professionals.
Profound understanding, using the triangular pyramid model, might be essential in the humanresource management for medical professionals. Or it might end in failure to maintain the function of
the hospital. Medical services in hospital are strongly depended on the medical professionals, that is,human resource management is the key to perform the efficient hospital management. The executive
manager of hospital should be well versed in management skills as well as medical knowledge toprovide better medical services for the public patients. Hoping that it would increase the number of
researchers who are well versed in medical knowledge and management skill, I would like tocontribute to furnish the splendid and better medical services for the public patients with the proper
medical professionalism.

REFERENCES
Akutsu J. (1995) ISEI, “Adeptus Medicus”, Tokyo: Fukushodo.
Allen, N. J., and J. P. Meyer. (1990) The measurement and antecedents of affective, continuance and normative
commitment to the organization, Journal of Occupational Psychology, Vol.63, No.1, pp.1-18.
Barney, J. B. (1991) Firm Resources and Sustained Competitive Advantage, Journal of Management, Vol.17
No.1, pp.99-120.
Collins J. C. and J. I. Porras. (1994) Built to Last: Successful Habits of Visionary Companies, New York, NY:
Harper Collins Publishers, Inc.

38

Crawshaw, R. S. (1970). The Contemporary Use of Medical Oaths. Journal of Chronic Disease, Vol.23,
pp.145-150.
Davis-Blake, A., and B. Uzzi. (1993) Determinants of Employment Externalization: A Study of Temporary
Workers and Independent Contracting, Administrative Science Quarterly, Vol.38, No.2, pp.195-223.
Dorman, J. (1995) The Hippocratic Oath. Journal of American College Health, Vol. 44, pp.84-89.
Duff, P. (2002) Professionalism in Medicine: An A-Z Primer, Obstetrics and Gynecology, Vol.99, No.6,
pp.1127-1128.
Edelstein, L. (1943) The Hippocratic Oath: Text, Translation, and Interpretation. Baltimore, IN Temkin O. and
C.L. Temkin (eds.), (1987) Ancient Medicine: Selected Papers of Ludwig Edelstein, Baltimore, ML Johns
Hopkins University Press.
Eisenberger, R., R. Huntington, S. Hutchison, and D. Sowa. (1986) Perceived organizational support. Journal ofApplied Psychology, Vol.71, No.3, pp.500-507.
Freidson E. (2001) Professionalism: The Third Logic. Chicago, IL: The University of Chicago Press.
Furst, L. R. (2000) Medical Progress and Social Reality. State University of New York Press.
George, A. L. (1979) Case studies and theory development: The method of structured, focused comparison. In P.
G. Lauren (eds.), Diplomacy: New approaches in history, theory, and policy, pp. 43-68. New York, NY, Free
Press.
Grant, M. F. (1991) The resource-based Theory of Competitive Advantage: Implications for Strategy formulation,
California Management Review, Vol.33, No.3, pp.114-135.
Gross, E., and A. Etzioni. (1985) Organizations in society, Englewood Cliffs, NJ; Prentice-Hall.
Hasenfield, Y. (1992) Human Service Organizations, 2nd edition, Englewood Cliffs, NJ: Prentice-Hall.
Herzberg, F. (1966) Work and the Nature of Man, Cleveland, OH: World Pub. Co.
Hindle, D., and A. M. Yazbeck. (2005) Clinical pathways in 17 European Union countries: a purposive survey,
Australian Health Review, Vol.29, No.1, pp.94-104.
Iaffaldano, M. T. and P. M. Muchinsky. (1985) Job satisfaction and job performance: A meta-analysis.
Psychological Bulletin, Vol.97, No.2, pp.251-273.
Inui TS. (1992) The social contract and the medical school’s responsibilities. In White KL, Connelly JE, ed. The
Medical School’s Mission and the Population’s Health: Medical Education in Canada, the United Kingdom,
the United States, and Australia. New York, NY: Springer-Verlag, pp.23-52.
Jones, A. and R. Crandell. (1986) Validation of a short index of self-actualization. Personality and Social
Psychology Bulletin, Vol.12, No.1, pp.63-73.
Kamien, M. (1998) Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions, Medical
Journal of Australia, Vol.169, No.6, pp.318-321.
Kennedy, S. M. (2001) Treatment responsivity: reducing recidivism by enhancing treatment effectiveness. In
Motiuk, L. L. and R. C. Serin (Eds.), Compendium 2000 on Effective Correctional Programming , vol. 1.
Ministry of Supply and Services, Canada.
Lepak, D. P., and S. A. Snell. (1999) The Human Resource Architecture: Toward a Theory of Human Capital
Allocation and Development, Academy of Management Review, Vol.24, No.1, pp.31-48.
Long, S. O. (1984) The sociocultural context of nursing in Japan, Cult Med Psychiatry, Vol.8, No.2, pp.141-163.
Macer, D. R. J. (1990). Shaping Genes: Ethics, Law and Science of Using New Genetic Technology in Medicine
and Agriculture. Eubios Ethics Institute, pp. 1-17.
Maslow, A. H. (1970 second edition [1954 first edition]) Motivation and Personality, New York, NY: Harper andRow.
Mathieu, I., and D. Zajac. (1990). A review and meta-analysis of the antecedents, correlates, and consequencesof organizational commitment, Psychological Bulletin, Vol.108, No.2, pp.171-194.
McClelland, D. C. (1975) Power: The inner experience, New York, NY: Irvington Publishers, Inc.
McClelland, D. C., and D. H. Burnham. (1976) Power is the great motivator, Harvard Business Review, Vol.54,
No.2, pp.100-110.
Medical Professionalism Project. (2002) Medical professionalism in the new millennium: a physicians’ charter.
Medical Journal of Australia, Vol.177, No. 5, p263-265.
Meyer, J. P., and N. J. Allen. (1984) Testing the ‘side-bet theory’ of organizational commitment: Somemethodological considerations. Journal of Applied Psychology, Vol.69, No.3, pp.372-378.
Meyer, J. P., and N. J. Allen. (1988) Links between work experiences and organizational commitment during thefirst year of employment: A longitudinal analysis. Journal of Occupational Psychology, Vol.61, No. ,pp.195-210.
Meyer, J. P., N. J. Allen, and C. A. Smith. (1993) Commitment to organizations and occupations: Extension andtest of a three-component conceptualization, Journal of Applied Psychology, Vol.78, No.4. pp.538-551.
Ministry of Health, Labor and Welfare (1999) Annual Reports on Health and Welfare 1998-1999 Social Security
and National Life Volume 2 II Outline of the Systems and Basic Statistics.

39

Moore, F. D. (1995) A miracle and a privilege recounting a half century of surgical advance. Washington D.C.:
Joseph Henry Press.
Mowday, R. T., L. W. Porter, and R. M. Steers. (1982) Employee-organization linkages, in Warr, P. ed.,Organizational and occupational psychology, New York, NY; Academic Press.
Mowday, R. T., R. M. Steers, and L. W. Porter. (1979) The measurement of organizational commitment. Journalof Vocational Behavior, Vol.14, 224-247.
Orr, R. D., N. Pang, E. D. Pellegrino, and M. Siegler. (1997) The Use of the Hippocratic Oath: A Review ofTwentieth Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. andCanada in 1993. Journal of Clinical Ethics, Vol. 8, pp. 377-388.
Parsons T. (1951) The Social System. New York, NY, Free Press pp.428-479.
Percival T. (1803) Medical Ethics or a Code of Institutes and Precepts Adapted to the Professional Conduct ofPhysicians and Surgeons. Manchester, S. Russell.
Porter, L. W., R. M. Steers, R. T. Mowday, and P.V. Boulian. (1974) Organizational commitment, job
satisfaction, and turnover among psychiatric technicians, Journal of Applied Psychology, Vol.59, No.5,
pp.603-609.
Savage, Y. (2004) Is that really my job? A guide to job profiling, British Journal of Community Nurses. Vol.9,
No.10, pp.426-428.
Schneider, B. (1985) Organizational Behavior. Annual Review of Psychology, Vol.36, pp.573-611.
Schuler, R., and I. MacMillan. (1984) Gaining Competitive advantage through Human Resource Practices,
Human Resource Management, Vol.23, No.3, pp.241-255.
Schuster, E. (1998) The Nuremberg Code: Hippocratic ethics and human rights. Lancet, Vol.351, No.9107, pp.
974-978.
Schwab, D. P. and Cummings, L. L. (1970) Theories of performance and satisfaction: A review. Industrial
Relations, Vol.9, pp.408-430.
Shostrom, E. L. (1964) An inventory for the measurement of self-actualization. Educational and Psychological
Measurement, Vol.24, No.2, pp.207-218.
Smith, D. C. (1996) The Hippocratic Oath and modern medicine. Journal of the History of Medicine and Allied
Sciences, Vol. 51, No. 4, pp. 484-500.
Stebbing, J., S. Mandalia, S. Portsmouth, P. Leonard, J. Crane, M. Bower, H. Earl, and L. Quine. (2005) A
questionnaire survey of stress and bullying in doctors undertaking research, Postgraduate Medical Journal,
Vol.80, No.940, pp.93-96.
Steers, R. M. (1977) Antecedents and outcomes of organizational commitment, Administrative Science
Quarterly, Vol.22, No.1, pp.46-56.
Tao, M., H. Takagi. , M. Ishida, and K. Masuda. (1998) A study of antecedents of organizational commitment.
Japanese Psychological Research, Vol.40, No.4, pp.198-205.
Teece, D. J., G. Pisano, and A. Shuen. (1997) Dynamic Capabilities and Strategic Management, Strategic
Management Journal, Vol.18, No.7, pp.509-533.
Temkin O. (1966) In Memory of Ludwig Edelstein, Bulletin of the History of Medicine, No. 40, pp. 1-42.
Thomas K. (2001) The Oxford Book of Work, Oxford, UK: Oxford University Press.
Thorpe. K., and R. Loo. (2003) Balancing professional and personal satisfaction of nurse managers: current andfuture perspectives in a changing health care system, Journal of Nursing Management, Vol.11, No.5,
pp.321-330.
Ulrich, D., and D. Lake. (1990) Organizational Capability: Competing from the Inside Out, New York, NY: John
Wiley and Sons.
Ulrich D. (1996). Human Resource Champions: The Next Agenda for Adding Value and Delivering Results,
Cambridge, MA: Harvard Business Press.
Vickers, M. D. (1981) Medical manpower and the career structure: a new approach, British Medical Journal(Clinical Research Edition). Vol.282, No.6279, pp.1854-1857.
Wernerfelt, B. (1984) A Resource-Based View of the Firm, Strategic Management Journal, Vol.5, No.2,
pp.171-180.
Williams, J. R. (2005) Principal features of medical ethics, in, Ethics Unit of World Medical Association, ed,
WMA Medical Ethics Manual, Ferney-Voltaire Cedex, France: World Health Communication Associates.
Wright, P. M., and G. C. McMahan. (1992) Theoretical Perspectives for Strategic Human Resource Management,
Journal of Management, Vol.18, No.2, pp.295-320.
Wynia M. K., S. R. Latham, A. C. Kao, J. W. Berg, and L. L. Emanuel. (1999) Medical Professionalism inSociety, New England Journal of Medicine, Vol.341, No.21, pp.1612-1616.

40

Appendix A

A-1

Lists of Questionnaire for the Survey

Items from the Organizational Commitment Scales*

Affective Organizational Commitment
1.* I do not feel like part of a family at (name of hospital).
2.
I feel emotionally attached to (name of hospital).
3.
Working at (name of hospital) has a great deal of personal meaning for me.
4.
I feel a strong sense of belonging to (name of hospital).
5.* (Name of hospital) does not deserve my loyalty.
6.
I am proud to tell others that I work at (name of hospital).
7.
I would be happy to work at (name of hospital) until I retire.
8.
I really feel that any problems faced by (name of hospital) are also my problems.
9.
I enjoy discussing (name of hospital) with people outside of it.
Continuance Organizational Commitment
I am not concerned about what might happen if I left (name of hospital) without having anotherposition lined up.
2.
It would be very hard for me to leave (name of hospital) right now, even if I wanted to.
3.
Too much in my life would be disrupted if I decided I wanted to leave (name of hospital) now.
4.
It wouldn’t be too costly for me to leave (name of hospital) now.
5.* Right now, staying with (name of hospital) is a matter of necessity as much as desire.
6.
One of the few, serious consequences of leaving (name of hospital) would be the scarcity ofavailable alternatives.
7.
One of the reasons I continue to work for (name of hospital) is that leaving would requireconsiderable sacrifice–another organization may not match the overall benefits I have here.
1.

Normative Organizational Commitment
1.* I do not feel any obligation to remain with (name of hospital).
2.
Even if it were to my advantage, I do not feel it would be right to leave (name of hospital) now.
3.
I would feel guilty if I left (name of hospital) now.
4.
(Name of hospital) deserves my loyalty.
5.
It would be wrong to leave (name of hospital) right now because of my obligation to the people
in it.
6.
I owe a great deal to (name of hospital).
Responses to each item are measured on a 7-point scale with scale point anchors labeled: strongly disagree,
moderately disagree, slightly disagree, neither disagree nor agree, slightly agree, moderately agree, and strongly
agree. An asterisk (*) denotes a negatively phrased and reverse scored item.
Source: Questionnaire from “Commitment and perceived organizational support” by LaMastro.

A-2
Short Index of Self-Actualization (SISA)
1.
I do not feel ashamed of any of my emotions.
2.*
I feel I must do what others expect me to do.
3.
I believe that people are essentially good and can be trusted.
4.
I feel free to be angry at those I love.
5.*
It is always necessary that others approve of what I do.
6.*
I don’t accept my own weaknesses.
7.
I can like people without having to approve of them.
8.*
I fear failure.
9.*
I avoid attempts to analyze and simplify complex domains.

41

10.
11.*
12.
13.*
14.*
15.

It is better to be yourself than to be popular.
I have no mission in life to which I feel especially dedicated.
I can express my feelings even when they may result in undesirable
consequences.
I do not feel responsible to help anybody.
I am bothered by fears of being inadequate.
I am loved because I give love.

* Results for these questions are reverse-scored so that more self-actualizing responses produce higher scores.
Source: Jones, A. and R. Crandall (1986) Short index of self actualization IN: Lester P, E. and L. K. Bishop(2001) Handbook of tests and measurement in education and the social sciences. 2nd ed. Lancaster, PA:
Technomic Publishing Co. pp. 280-281. Original publication has been listed in the references.

Appendix B

B-1

B-2.

Statistical data of the survey study

Cross-tabulation of the samples
Doctor

Nurse

Others

Total

University Hospital

22

63

0

85

Public Hospital

21

50

7

78

Private Hospital

6

71

14

91

Total

49

184

21

254

Descriptive statistics of whole samples
numberminimum

maximummeanStandard deviation

OC

251

-26.00

29.00

0.048

10.056AC

251-20.00

17.00

0.339

6.001

CC

251

-9.00

11.00

1.367

3.874

NC

251

-17.0012.00-1.657

5.261

SA

253

-10.00

10.00

0.968

3.524

OC: organizational commitment, AC: affective commitment, CC: continuance commitment,
NC: normative commitment, SA: self-actualization.

42

B-3

Frequency distribution of Organizational Commitment Scales

University Hospital

Public Hospital

Private Hospital

40

30

20

10

0

-10

-20

*

-30

*
*
-40
The mean values are indicated as solid lines. Broken lines indicate ±1SD and short broken lines ±2SD. The
asterisks indicate outliers that are over three times of standard deviation (±3SD).

43

B-4

Frequency distribution of Short Index of Self-Actualization

University Hospital

Public Hospital

Private Hospital

30

20

10

0

-10

-20

*
-30
The mean values are indicated as solid lines. Broken lines indicate ±1SD and short broken lines ±2SD. The
asterisks indicate outliers that are over three times of standard deviation (±3SD).

44

B-5

Descriptive statistics of each score(A) Organizational commitment (OCS)

Doctor
Nurse
Others
Total

University Hospital
N
mean
SD
22
-3.50
7.29
63
-7.21
6.96
0
N/A
N/A
85
-6.25
7.19

Public Hospital
N
mean
SD
21
1.76
11.34
50
-0.14
8.78
7
4.71
13.88
77
0.82
10.00

Private Hospital
N
mean
SD
6
2.83
11.23
71
5.70
8.77
14
5.00
10.63
89
5.39
9.16

Public Hospital
N
mean
SD
21
1.33
6.73
49
-1.63
4.63
7
4.14
9.08
77
-0.30
5.97

Private Hospital
N
mean
SD
6
-0.83
9.45
69
2.25
4.63
14
4.50
7.76
89
2.39
5.66

Public Hospital
N
mean
SD
21
-0.86
3.61
49
4.12
2.90
7
-2.29
3.45
77
2.18
4.06

Private Hospital
N
mean
SD
6
4.33
3.72
69
2.29
3.47
14
0.36
4.13
89
2.12
3.67

Public Hospital
N
mean
SD
21
1.29
4.36
49
-2.63
5.75
7
2.86
5.49
77
-1.06
5.73

Private Hospital
N
mean
SD
6
-0.67
5.05
69
1.16
3.93
14
0.14
4.38
89
0.88
4.07

Public Hospital
N
mean
SD
21
1.86
2.89
50
0.78
3.42
7
0.43
2.95
78
1.04
3.24

Private Hospital
N
mean
SD
6
2.17
2.04
70
0.13
3.60
14
-0.93
5.30
90
0.10
3.85

Affective commitment

Doctor
Nurse
Others
Total

University Hospital
N
mean
SD
22
2.59
6.90
63
-2.57
4.79
0
N/A
N/A
85
1.24
5.83

Continuance commitment

Doctor
Nurse
Others
Total

University Hospital
N
mean
SD
22
-2.41
3.59
63
0.62
3.09
0
N/A
N/A
85
-0.16
3.47

Normative commitment

Doctor
Nurse
Others
Total

University Hospital
N
mean
SD
22
-3.68
5.12
63
-5.25
3.85
0
N/A
N/A
85
-4.85
4.24

(B) Self-actualization (SISA)

Doctor
Nurse
Others
Total

University Hospital
N
mean
SD
22
2.77
4.34
63
1.49
2.69
0
N/A
N/A
85
1.82
3.22

The sample number (N), the means and standard deviation (SD) in each category of the hospitals areshown according the medical professionals. In University hospitals, the samples were collected fromdoctors and nurses and not available (N/A) from other categories of professionals.

45

B-6

Pearson correlation coefficients matrix

OC

AC

CC

NC

SA

r
p
N
r
p
N
r
p
N
r
p
N
r
p
N

OC
1
.
251
0.759*
0.000
251
0.291*
0.000
251
0.831*
0.000
251-0.123
0.053
250

AC
0.759*
0.000
251
1
.
251
-0.219*0.000
251
0.472*
0.00
251-0.013
0.834
250

CC
0.291*
0.000
251-0.219*
0.000
251
1
.
251
0.069
0.279
251
-0.168*
0.008
250

NC
0.831*
0.000
251
0.472*
0.000
251
0.069
0.279
251
1
.
251
-0.094
0.136
250

SA
-0.1230.053
250-0.0130.834
250-0.168*0.008
250-0.094
0.136
250
1
.
253

* Correlation is significant at the 0.01 level (two-tailed).

B-7

Analysis of variance table (Controlling for the category of hospitals)
Df

SS

MS

F

p

OC
Error
Total

2
248
250

5956.924
19324.502
25281.426

2978.462
77.92138.224

0.000

AC
Error
Total

2
248
250

617.555
8386.660
9004.215

308.778
33.817

9.131

0.000

CC
Error
Total

2
248
250

301.4903450.789
3752.279

150.745
13.91410.834

0.000

NC
Error
Total

2
248
250

1463.2065455.328
6918.534

731.60321.99733.259

0.000

SA
Error
Total

2
250
252

130.4092999.338
3129.747

65.20511.997

5.435

0.005

46

B-8

Multiple comparison: Tukey honestly significant difference

Controlling for the category of hospitals
VariablesOC(I) (J)DM (I-J)SEp

1-7.065*-11.640*
7.065*-4.575*
11.640*4.575*-0.937-3.629*0.937-2.692*3.629*
2.692*-2.347*-2.288*2.347*
0.058
2.288*-0.058-3.782*-5.724*
3.782*-1.941*5.724*
1.941*
0.785
1.724*-0.7850.939-1.724*-0.939

1.389
1.339
1.389
1.374
1.339
1.374
0.915
0.882
0.915
0.905
0.882
0.905
0.587
0.566
0.587
0.581
0.566
0.581
0.738
0.711
0.738
0.723
0.711
0.730
0.543
0.524
0.543
0.536
0.524
0.536

0.000
0.000
0.000
0.003
0.000
0.003
0.563
0.000
0.563
0.009
0.000
0.009
0.000
0.000
0.000
0.994
0.000
0.994
0.000
0.000
0.000
0.023
0.000
0.023
0.319
0.003
0.319
0.188
0.003
0.188

2
3
1

AC

2
3
1

CC

2
3
1

NC

2
3
1

SA

2
3

2
3
1
3
1
2
2
3
1
3
1
2
2
3
1
3
1
2
2
3
1
3
1
2
2
3
1
3
1
2

95% Confidence Interval
Lower
Upper
-10.340-3.791-14.797-8.4843.791
10.340-7.815-1.3368.484
14.7971.336
7.815-3.094
1.221-5.708-1.549-1.221
3.094-4.826-0.558
1.549
5.708
0.558
4.826
-3.730-0.963-3.622-0.9540.963
3.730-1.311
1.427
0.954
3.622
-1.4271.311-5.522-2.042-7.401-4.0462.042
5.522-3.663-0.220
4.046
7.401
0.220
3.663
-0.495
2.066
0.488
2.959
-2.0660.495-0.3252.202-2.959-0.488-2.202
0.325

Hospitals are categorized as university hospitals (1), public hospitals (2) and private hospitals (3).
DM: difference of mean, SE: standard error, p: significance probability* The mean difference is significant at the 0.05 level.

47

B-9

Comparison between doctor and nurse(A) Descriptive statistics

Profession
1
2
1
2
1
2
1
2
1
2

Organizational commitment
Affective commitment
Continuance commitment
Normative commitment
Self-actualization

N
49
181
49
181
49
181
49
181
49
183

mean
-0.469-0.3761.633-0.481-0.9182.204-1.184-2.099
2.306
0.776

SD
9.891
9.838
7.091
5.145
4.122
3.459
5.255
5.232
3.513
3.298

SEM
1.413
0.731
1.013
0.382
0.589
0.257
0.751
0.389
0.502
0.244

Profession 1: medical doctor, 2: nurse.
N: number, SD: Standard deviation, SEM: standard error of the mean(B) Independent sample test between doctor and nurse
Levene’s test

OC
AC
CC
NC
SA

p
HV F
yes 0.515 0.474
noyes 6.102 0.014
noyes 2.608 0.108
noyes 0.001 0.977
noyes 0.454 0.501
not

Test of difference of two population means
95% CI
Lower
Upper
Df
p
DM
SE

-0.059 228-0.059 75.703
2.339 228
1.952 62.321-5.374 228-4.860 67.388
1.086 228
1.083 75.773
2.845 230
2.742 72.268

0.953
0.953
0.020
0.055
0.000
0.000
0.279
0.282
0.005
0.008

-0.094-0.0942.113
2.113-3.123-3.123
0.916
0.916
1.530
1.530

1.586
1.591
0.904
1.083
0.581
0.646
0.843
0.845
0.538
0.558

-3.219-3.2630.333-0.051-4.268-4.405-0.746-0.768
0.470
0.418

3.032
3.075
3.894
4.277
-1.978-1.840
2.576
2.600
2.590
2.642

HV: homogeneity of variance, p: significance probability, Df: degree of freedom, DM: difference ofmean, SE: standard error, CI: confidence interval of the difference.

48

B-10

Results of multiple regression analyses(A) Category of hospital and profession predicting organizational commitment
Hospital
Profession

B
5.952-0.806β0.494-0.041

t-ratio
8.522-0.715

p
0.000
0.475

R2 = 23.4%
adjusted R2 = 22.8%

Category of hospital and profession predicting affective commitment
Hospital
Profession

B
1.917-0.552β0.266-0.048t-ratio
4.165-0.743

p
0.000
0.458

R2 = 6.6%
adjusted R2 = 5.9%

Category of hospital and profession predicting continuance commitment
Hospital
Profession

B
1.028
0.612

β
0.221
0.082

t-ratio
3.461
1.278

p
0.001
0.203

R2 = 6.6%
adjusted R2 = 5.8%

Category of hospital and profession predicting normative commitment
Hospital
Profession

B
3.007-0.867β0.477-0.085t-ratio
8.112-1.450

p
0.000
0.148

R2 = 6.6%
adjusted R2 = 5.9%

(B) Category of hospital and profession predicting self-actualization
Hospital
Profession

B-0.665-1.129β-0.157-0.165t-ratio-2.469-2.593

p
0.014
0.010

B = Unstandardized Coefficients, β =Standardized Coefficients.

49

R2 = 6.7%
adjusted R2 = 5.9%

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