Social science research in healthcare focuses on patient wellbeing, methods to improve patient care, ways to provide a voice for patients, and ways to advocate for them (1-4). Patient care delivery is a complicated social process involving many professional groups. In addition to doctors and nurses, allied healthcare professional groups are critical for diagnoses and delivery of care (5). Medical technologists are workers who typically operate diagnostic machinery and the results of their work provide doctors and nurses with the information that they need to make treatment decisions. Cano et al. perform a phenomenological analysis of this population within the context of the Philippines healthcare system to understand the factors that drive job satisfaction within this group of health care workers (HCWs) (6).
The Philippines healthcare system is suffering from a scarcity of skilled medical technologists attributed to low job satisfaction and high HCW turnover and brain drain. Medical technologists work in laboratories of healthcare establishments and constitute the backbone of diverse medical tests and procedures. Cano et al. in their work have conceived of job satisfaction from the employee’s lens and attributed it to their feelings, experiences, and expectations from their work environment. The laboratory environment in which the medical technologists worked was divided into having physical, social, and psychological elements to it that affected the employees either positively or adversely. Teamwork, effective communication with colleagues, and psychological safety, were stressed the most by the authors as being conducive for worker productivity, emotional stability of employees and finally employee retention at the workplace (6).
The study was conducted around the time of the coronavirus disease 2019 (COVID-19) pandemic which had gargantuan consequences on all aspects of societal life, specifically in the sphere of healthcare. This was a global health phenomenon that tested the strength and success of healthcare systems of First, Second and Third World countries (7,8). It was not a surprise that healthcare systems that had a weak undergirding crumbled including of some First World Countries like the United States struck by this behemoth blow to their medical system (9). HCWs were frontliners putting up an admirable fight against the COVID-19 tempest, sometimes emerging out victorious and at other times succumbing to it but not without their contribution (10). Societies across the globe responded variedly to these HCWs, their reactions to HCWs’ dutybound labor and sacrifices ranged from commendations to loud, clattering applauds to hatred to fear to stigmatization and unfortunately verbal and physical assault (11,12). There are studies, however, that show that society’s tumultuous and vacillating relationship with HCWs, especially physicians, precedes the COVID-19 pandemic (13-16). Medical technologists working in the laboratories in Metro Manila, in the Philippines have not been spared these ambivalent societal reactions. Cano et al. in their study on job satisfactions of HCWs have shone light onto this issue and made efforts to voice the grievances of HCWs in Metro Manila on their behalf. In particular, they have highlighted the faulty healthcare revenue model of the Filipino government, and shortage of nurses, physicians and medical technologists leading to burnout and high turnover of HCWs. Cano et al. have held accountable the phenomenon of brain drain of skilled HCWs in Metro Manila to these low salaries, exhaustion from excessive workload during a pandemic due to staff shortage, and the taken for granted attitude of the government towards HCWs. As of this study the Philippines is currently 4,500 medical technologists short of the optimum number (p3). This study is a phenomenological endeavor to explore the lived experiences of medical technologists in Metro Manila and their perception of job satisfaction, and what factors and forces they perceive of to be conducive to attain higher levels of job satisfaction. They took a deep dive into the works of pioneers of phenomenology like Husserl, Heidegger and Merleau-Ponty and applied it to understand the meanings and values underlying the responses of their interlocutors. Purposive sampling was used effectively to deliberately select interlocutors for one-time, semi-structured virtual interviews. Although the sample size is considered small from a statistical perspective, the authors rationalized their stance adequately citing previous works on data saturation (p4), and inclusion and exclusion criteria in qualitative studies. Moreover, for qualitative studies, it is the depth of analysis rather than the statistical power or large ‘N’ that is critical for evaluating the insights generated (17). Based on the saturation techniques and inclusion and exclusion criteria the authors arrived at a sample size of 13 Philippine Department of Health registered medical technologists with at least 3 years of experience working in private hospitals. Cano et al. drew inspiration from Colaizzi’s seven-step method of analysis (p4) for analyzing their data. One of the aspects of Colaizzi’s method is that it attempts to perform data validation through respondent consultation of the analyzed results. This method also allowed the authors to identify themes from the qualitative data. One of the most significant contributions that emerged from their data analysis was the development of the analytical concept of the fire triangle of job satisfaction.
The fire triangle is a mnemonic device used to explain the three constituent components that are required for a fire to be sustained. The “sides” of the fire triangle are fuel, oxygen, and heat. Public service education on fire mitigation teaches that if any one of these components is removed the fire will no longer continue to burn. Typically, it is used to teach how limiting either fuel, oxygen, or heat can be used to contain fire (18). Cano et al. adapt this concept and use “fire” to imply the desire of a medical technologist in a private healthcare setting to continue working and contributing to the healthcare and wellbeing of patients within the Philippines. They arranged their conceptual elucidation to try and answer the question—“what ensures the desire of medical technologists to continue to want to work within the Philippines?”.
This conceptual framing helped deduce the three sub-concepts, or the three sides of the triangle—that they term the Force of the 3Ps, in other words, Force of Purpose, the Force of Pursuit and the Force of People. The themes that emerged from the interview data about the lived experiences of the respondents were coded within these 3Ps depending on how the medical technologists defined and described what each of them thought contributed to their satisfaction with their work. Force of Purpose was associated with the participants’ rationale behind choosing this profession and had an emotional tone in their responses, based on values regarding fulfilling duties, altruism in taking care of society at the expense of their safety, and the feeling of self-confidence and gratification in converting knowledge gathered during training into practical application (p6). On the other hand, Cano et al. also took note of the factors that negatively affected their respondents’ job satisfaction, and explained how routinization of the job without passion or emotions was negatively viewed. The Force of Pursuit arose from a more materialistic expectation from their jobs in terms of remuneration, job benefits, work experience, and future opportunities from the current job. The issue of underpayment was broached and the disproportionate workload and salary structure and how it could be the sole demotivating factor bringing down job satisfaction levels was heavily emphasized. Interestingly, the medical technologists did not limit their job satisfaction to only the work environment or salary structure or relationship with their colleagues but also to opportunities to develop specialized skills and expand their knowledge base through educational courses or continuing professional development, especially if their current job was offering them these prospects. Finally, the Force of People was a theme that developed from a sense of acknowledgement and recognition by the people they were serving. The respondents associated job satisfaction with appreciation from patients, which motivated them even more than salaries to carry on their challenging work especially as frontliners during a pandemic.
The acute shortage of doctors and nurses within the Philippines medical system is well documented, and several factors are held responsible for this shortage. Brain drain is often cited as a major factor drawing physicians away from the country. The Philippines is the second highest country in terms of the number of international medical doctors serving in the physician workforces of the United States, the United Kingdom, Australia, and Canada (19). Another analysis looking at the nursing workforce dynamics within the Philippines before and after a 2007 restriction of United States visas for nurses found that the relaxed visa conditions had led to the growth of nursing education within the Philippines. They argue that rather than causing brain drain, the emigration of nurses led to development of nursing training infrastructure and consequently qualified nurses within the Philippines (20). The ill-effects of brain drain have also been repudiated by Kenneth Ronquillo, a prior director of the Health Human Resource Development Bureau of the Department of Health stating, “In terms of absolute doctors and nurses, the Philippines has always had an ample supply”. Yet anecdotal evidence would suggest severe medical understaffing especially in rural areas, including examples of hospitals that were built with congressional funds that have remained unused and consequently become derelict over a decade due to lack of staff to run the hospital (21).
Respondents in Cano et al. have alluded to brain drain and the lack of career development as a medical technologist within the Philippines. These respondents are stark about the prospects of the job actively advising against it as a full-time career within the Philippines and suggesting using the experience to either move abroad or go to medical school (p8). It is within this milieu that this preliminary study provides a method to understand how to keep the fires of professional desire to remain in this field burning. Along with policy proposals, Cano et al. also provide further avenues for exploration including longer on-site interviews. The policy proposals that they put forward are to institute changes to the healthcare revenue model to ensure higher pay for the technologists, as well as measures to improve the safety and security of healthcare workplaces within which these technologists practice.
The shortage of medical professionals and the safety and security hazards within medical workplaces are not a problem only faced by the Philippines. Other developing countries like India also face doctor and nurse shortages (22,23). Also, within the Indian system, there was widespread adulation as well as condemnation of HCWs including physical assaults on doctors on hospital grounds (24). Even within the United States healthcare sector occupational violence is exceeded only by law enforcement (14). Pay, workload, and the omnipresent threat of violence pose challenges to the retention of doctors and nurses within developing country healthcare systems. This paper provides a methodology to understand and analyze the forces that maintain HCW retention. Using the fire triangle of job satisfaction methodology, different HCW populations can be analyzed, and their job motivations understood. Understanding the sides of the triangle fueling job satisfaction can help direct targeted policy proposals and address the attrition of allied HCWs.
This study is a small study with a limited number of respondents, but it provides insight into two avenues for further exploration and analysis. Firstly, it addresses medical technologists, a vital, yet overlooked class of healthcare professionals whose services and contributions go unrecognized. While there are reports and estimates of doctor and nurse emigration from the Philippines, similar estimates are not as widespread for this population. Career progression is more undefined for this population in comparison to doctors and nurses. They also face some of the security and safety issues faced by doctors and nurses. Secondly, this study provides an analytical approach for understanding staff retention by making an external analytical comparison to the well-known fire triangle. This categorization of their qualitative data makes it easier for policymakers to understand appropriate foci for policy development. I hope that more studies, especially from the developing world using other qualitative data collection techniques like participant observation or ethnographic observation (Bandage, Sort, and Hustle by Josh Seim) provides an example that focuses on allied HCWs with regards to paramedicine in the United States (25) will follow this study.
Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article did not undergo external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-75/coif). The author has no conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
- Alexander JA, Hearld LR, Mittler JN, et al. Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res 2012;47:1201-23. [Crossref] [PubMed]
- Hutchens K. "It Wasn't Very Public-Clinicy": Client Experiences at Faith-Based Pregnancy Centers. J Health Soc Behav 2023; Epub ahead of print. [Crossref] [PubMed]
- Stepanikova I, Mollborn S, Cook KS, et al. Patients' race, ethnicity, language, and trust in a physician. J Health Soc Behav 2006;47:390-405. [Crossref] [PubMed]
- Timmermans S. The Engaged Patient: The Relevance of Patient-Physician Communication for Twenty-First-Century Health. J Health Soc Behav 2020;61:259-73. [Crossref] [PubMed]
- Zajac S, Woods A, Tannenbaum S, et al. Overcoming Challenges to Teamwork in Healthcare: A Team Effectiveness Framework and Evidence-Based Guidance. Front Commun 2021;6: [Crossref]
- Cano EAA, Olano MLR, Ruanto FMO, et al. A phenomenological study of Filipino Medical Technologists’ forces for perceived job satisfaction amidst COVID-19 pandemic in the Philippines. J Public Health Emerg 2023;7:13. [Crossref]
- Moynihan R, Sanders S, Michaleff ZA, et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open 2021;11:e045343. [Crossref] [PubMed]
- OECD. The impact of COVID-19 on health and health systems. 2023. Available online: https://www.oecd.org/health/covid-19.htm
- CMS. National Health Spending in 2020 Increases due to Impact of COVID-19 Pandemic. 2021. Available online: https://www.cms.gov/newsroom/press-releases/national-health-spending-2020-increases-due-impact-covid-19-pandemic
- World Health Organization. Impact of COVID 19 on health and care workers: a closer look at deaths. 2021. Available online: https://apps.who.int/iris/bitstream/handle/10665/345300/WHO-HWF-WorkingPaper-2021.1-eng.pdf?sequence=1&isAllowed=y
- Roy A. Indians clap, ring bells to cheer emergency workers during coronavirus lockdown. Reuters. 2020. Available online: https://www.reuters.com/article/us-health-coronavirus-india-cheer-idUSKBN2190M7
- Ellis-Petersen H, Rahman SA. Indian doctors being evicted from homes over coronavirus fears. the Guardian. 2020. Available online: https://www.theguardian.com/world/2020/mar/30/indian-doctors-being-evicted-from-homes-over-coronavirus-fears
- Sarkar T. Harnessing Bourdieu’s social theory to understand the deteriorating doctor-patient-nurse relationship in West Bengal government hospitals. Front Sociol 2022;7: [Crossref] [PubMed]
- Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med 2016;374:1661-9. [Crossref] [PubMed]
- Brophy JT, Keith MM, Hurley M. Assaulted and Unheard: Violence Against Healthcare Staff. New Solut 2018;27:581-606. [Crossref] [PubMed]
- Anand T, Grover S, Kumar R, et al. Workplace violence against resident doctors in a tertiary care hospital in Delhi. Natl Med J India 2016;29:344-8. [PubMed]
- Small ML. ‘How many cases do I need?’: On science and the logic of case selection in field-based research. Ethnography 2009;10:5-38. [Crossref]
- Northwest Fire Science Consortium. What is? Fire Triangle. 2015. Available online: https://www.nwfirescience.org/sites/default/files/publications/FIREFACTS_Triangles.pdf
- Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-8. [Crossref] [PubMed]
- Abracar P, Theoharides CB. Brain gain: Providing healthcare workers with opportunities to migrate can increase education and supply of medical workers in origin countries. World Bank Blogs. 2021. Available online: https://blogs.worldbank.org/peoplemove/brain-gain-providing-healthcare-workers-opportunities-migrate-can-increase-education-and
- Finch S. Philippines brain drain: fact or fiction? CMAJ 2013;185:E557-8. [Crossref] [PubMed]
- Gill R. Nursing Shortage in India with special reference to International Migration of Nurses. Social Medicine 2011;6:52-9.
- Sharma DC. India still struggles with rural doctor shortages. Lancet 2015;386:2381-2. [Crossref] [PubMed]
- Basu K. Protests erupt across state after assault on NRS doctors. Telegraph India. 2019. Available online: https://www.telegraphindia.com/states/west-bengal/protests-erupt-across-state-after-assault-on-nrs-doctors/cid/1692261
- Seim J. Bandage, Sort, and Hustle. 1st edition. Oakland, CA, USA: University of California Press; 2020:271.
Cite this article as: Sarkar T. Keeping aflame the fire of job satisfaction—a phenomenological endeavor investigating medical technologists in the Philippines. J Public Health Emerg 2023;7:16.