Staff dissatisfaction in the theatre complex of a private hospital

Curationis 30(3): x-y The evident job dissatisfaction of nursing personnel in a theatre complex of a private hospital has seemingly led to an extremely high turnover rate of personnel. Several factors appear to be responsible for the discontent among nursing staff such as low staff levels, the continuous quest for cost-effectiveness in terms of staffing numbers, the flexi-time system, insufficiently experienced staff and inadequate care and maintenance o f equipment. As a requirement of the C3-Workbook (which sets requirements for staff appraisal) a quantitative, exploratory and descriptive research study was undertaken among all the nursing staff and technicians of a theatre complex in a private hospital. A questionnaire was employed to gather data in this census survey. The aim of the research was to identify the problems in this theatre section in order to take remedial steps in an attempt to re-establish a stable personnel corps which would not only benefit the functioning of the unit but could also contribute to the well being of staff. The findings indicate that dissatisfaction and negative feelings were experienced by the respondents as a result of working conditions, management’s lack of support and understanding, unequal distribution of work, unavailability of stock and supplies, remuneration not in line with actual hours worked, the seemingly unfair flexi-time system and insufficient staff numbers. Recommendations were made relevant to management’s role, the motivation of staff, shortage o f personnel and physical environment.


Introduction
A positive attitude toward one's job is called job satisfaction.In general, people experience this attitude when their work matches their needs and interests, when working conditions and rew ards are satisfactory, when employees like their co -w o rk ers, and w hen there are opportunities for growth, development and autonomy (Daft 2000: 470).Job satisfaction results in higher productivity, red u ced lab o u r tu rn o v er, red u ced absenteeism and a better worker corps en a b lin g the re a lisa tio n o f the organisational goals (Gerber, Nel & van Dyk 1998:229).Job dissatisfiers, on the other hand, encompasses aspects such as inadequate working conditions and pay, ineffective company policies, poor interpersonal re la tio n sh ip s, and u n su p p o rtiv e supervisors resulting in w ork being ex p erien ced as d issatisfy in g .As a consequence, employees may react by leaving the organisation, or actively and constructively attempt to improve the conditions by voicing their concerns.They may also wait passively for the conditions to improve, or by passively allowing conditions to worsen, their resentment would be evident in chronic absenteeism or lateness, reduced effort, and an increased error rate (Robbins 1996:196-7).
It is th ere fo re im p o rtan t for the organisation to deal with issues that cause d issa tisfa c tio n as they can negatively impact on the performance of many employees.The side effects of work related problems and dissatisfiers include ineffective management, poor working re latio n sh ip s, lack o f control over d ecisio n s affectin g o n e 's life, and overwork (Marriner-Tomey 1996:413).Em ployees are expected to assist in achieving the organisations' goals.For the em p lo y ee to carry out this responsibility, good working conditions should be provided, which include the p ro v isio n o f ad eq u ate p erso n n el, equipment and supplies, in addition to a safe and re la tiv e ly stress free environment (Morrison 1993:126).
Only a small percentage of nurses choose to w ork in the o p eratin g th eatre.Nonetheless, it is safe to state that a high percentage o f the permanent nursing staff working in theatre are there out of choice.This however, does not guarantee a stress-free and positive environment.It appears in general as if the nursing staff working in this particular theatre complex is d issa tisfie d , th is is based on o b serv atio n and in tera ctio n o f the researcher with members o f the nursing staff.

Background
The selected private hospital in Pretoria at which the research was performed, is a 352 bed hospital which caters for medical conditions over a wide spectrum, and has been in existence for eight years.This study w as fo cu ssed on the theatre complex and its personnel.
The theatre com plex consists o f 13 theatres which are divided into two separate entities.The study was aimed at one o f these sections com prising multiple disciplines in eight theatres.The staff establishment for this section o f theatre co n sists o f 24 professional nurses (o f which ten have a theatre technique qualification), seven staff nurses, five auxiliary nurses and 3 surgical technicians.With a number of first and second year students passing through for learning experiences.
Initially the staff for this hospital was handpicked for their knowledge, skills, personality and experience.Since the takeover o f the hospital by a large corporation, the organisational culture and climate has changed considerably with apparent detrim ental effects on patient care standards and personnel well being.This is substantiated by patient complaints identified during pre-and post -operation visits by theatre staff.
Due to the number o f specialised services provided by the different surgeons at this hospital, the unpredictability o f time frames related to theatre list completion and unplanned theatre cases, there is alw ays a m easure o f u n ce rtain ty regarding the required coverage to ensure adequate, safe nursing practice standards in theatre.While an attempt is made to consider the acuity levels o f patients established by staffing norms, the absolute minimum o f staff members for booked cases are rostered, in order to strive for cost effectiveness.In practice, this however, leads to a sense o f immense pressure for nursing staff and general dissatisfaction because it leads to crisis management o f theatre cases.
The implementation o f the "Hands-ontim e-m a n a g em en t-system ", w hich requires that nurses have to clock in and out when reporting for duty, takes into account all hours worked on each day per month but does not specifically indicate a-social hours worked after hours or weekends.The effect thus, of being offered time off, when the units allow it, results in the a-social hours worked being considered as "normal time" depriving employees of the special rates remuneration.If a nurse worked aso cia l hours during the-m onth but requires hours to make up her minimum requirements because she was requested not to come on duty due to a slack time at work, this results in special tariff hours being considered normal working time.
O ther facto rs lead in g to s ta ff dissatisfaction in this theatre section are amongst others the following:

Problem statement
It is evident that several factors exist which contribute to job dissatisfaction amongst the nursing staff which leads to a lowering o f standards, a sense o f not being good enough and conflict at home due to long and unpredictable working hours and consequently to a high staff tu rn o v e r in th is th e a tre sectio n .Unfortunately, resigning employees do not always provide the true reasons for their dissatisfaction and subsequent departure.

Research questions
From the p re v io u s d iscu ssio n the following research question arises: W hich fa c to rs co n trib u te to s ta ff dissatisfaction, a negative attitude and lowering o f standards?

Aim of the research
The aim o f this study was to identify the problems in this theatre section in order to take remedial steps so that a stable personnel corps could be re-established who are recognised for their inputs and loyalty, who are enthusiastic about the challenges in their day-to-day jobs, and w hich in turn sh o uld lead to an improvement in morale and standards.

Objectives
The objectives o f this study were to • determine the reasons for job dissatisfaction amongst nurses in this particular unit • make recommendations for improvement o f working conditions o f these nurses

Assumption
Assumptions refer to basic principles that are assumed to be true without proof or verification (Polit & Hungler 1993: 13).
The follow ing assum ption serves as point of departure for this study: • Fulfilled and content employees within a given, fair and just structure will be driven to perform optimally.

Research methodology
The research methodology describes the design and methods to be implemented during the research project.

Research design
Mouton (2001:55) defines the research design as a plan o f how one intends to conduct the research.The quantitative ap p ro ach w ith an ex p lo ra to ry and descriptive design was used for this study.The quantitative approach allows the researcher to analyse data, using numerical information through statistical procedures (Brink 1996:13).
E x p lo rativ e re searc h ex p lo res the dimensions of a phenomenon, the manner in which it is manifested and the other factors with which it relates, thus the aim is to gain insight into a specific situation (Rubin & Babbie 2001:123).
A descriptive design aims at obtaining com plete and accurate inform ation through observation, in order to provide a picture of the situation as it naturally happens, the descriptive design is also used to identify problems within current practice (Bums & Grove 1997:250).

Instrumentation
The survey method was applied by using a self-compiled questionnaire to obtain the views o f the staff in relation to problems experienced in the workplace.
Compilation o f the questionnaire was based on the literature, the researcher's lo n g stan d in g ex p e rien ce and involvem ent in this theatre unit and problems related by staff on a day-today bases.
The q u estio n n aire co n sisted o f 13 questions with either a YES or NO response, and provided the opportunity for further comments.

Validity
Validity is the ability of an instrument to measure the variable that it is intended to measure (de Vos, Strydom, Fouche & Delport 2002:166).The questionnaire was given to an experienced unit manager to assess the face and content validity of the questions.There were no alterations suggested.

Reliability
Reliability relates to the accuracy and precision o f an instrument as the degree o f consistency or agreement between two independently derived set o f scores from the same instrument.Reliability thus refers to the dependability, stability, consistency, predictability and accuracy o f the instrument (de Vos et al 2002:168).In an attempt to ensure reliability o f the data collection instrument for this study, the formulation o f questions were clear and to the point, striving to avoid any ambiguity.

Population
The population refers to the entire group o f persons who are o f interest to the researcher and which meets the criteria (Brink 1996:132).The population for this study consisted o f all the nurses and surgical technicians w orking in this theatre unit.This group o f nurses co n sisted o f the u n it m anager, professional nurses, enrolled nurses and auxiliary nurses.

Sample
As the m entioned s ta ff com ponent com prises 36 nurses (from different ca te g o ries) and th ree su rg ical technicians, it was envisaged to use the entire component.Thus a sample was not drawn but a census was done.Thirty nine questionnaires were distributed, of which all were returned but one, as the particular staff member was on leave at that point in time, giving a response rate o f 97 percent.

Data gathering
The questionnaires were distributed by the researcher to all nurses and surgical technicians according to the roster list.Respondents were requested to mail the completed questionnaires in a sealed container provided for this purpose by a set date.

Data analysis
According to Brink (1996:178) data analysis entails categorising, ordering, manipulating and summarising data and describing them in meaningful terms.D e sc rip tiv e s ta tistic s w as u sed to describe and summarise the data.

Ethical considerations
A requirement o f the C3-Workbook is that a research project be performed.In view o f this requirement it was decided to use the theatre unit and its problems as a focus area.Permission was granted by the unit manager.The theatre staff were informed by the unit manager at a general p erso n n el m eeting o f the p en d in g re searc h and all w ere in v ite d to participate if they felt so inclined thus providing for informed consent.
The following relevant ethical principles w ere taken into co n sid eratio n in conducting this research, namely respect for anonymity and confidentiality.These principles w ere discussed w ith the participants and could be maintained as the respondents were not required to put their names on the questionnaire (Polit & Hungler 1993:31).

Definition of terms •
A-social hours A-social hours refer to the working hours o f nurses which are required after normal 8 am to 4 pm shifts, during night time, over weekends and public holidays.

•
Fad Focus Fad focus is an abbreviation for fanatical attention to detail.Each member of staff in the theatre unit is responsible for a specific item/aspect/issue on which he/ she focuses to ensure quality control throughout the theatre complex, and serves as an ongoing in-service training programme.

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Hands-on-managementsystem The H ands-on-m anagem ent-system refers to a clock in process whereby staff members press their hand against an electronic device to record the time of their arrival and departure from the work unit.

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Maximising performance Maximising performance is a performance assessm en t system , co n tain in g the following five performance areas, on which staff have to submit assignments in order to be assessed and rated

Results
The results will be discussed according to the 13 questions contained in the q u estio n n aire .W here p artic ip a n ts responded by ticking both the YES and NO options to the same question, their response was considered as 'uncertain' or 'undecided.' Due to the rounding of percentages the totals to all questions do not amount to exactly 100 percent.

•
B ased on the question regarding the existence o f negative feelings in the place o f work, half (20; 53%) o f the participants indicated that this was in fact not so, however it must be noted that sixteen (42% ) o f the respondents noted that they experienced negative feelings in theatre.Two (5%) respondents were undecided.

•
More than half (21 ;55%) o f the respondents ascribed the negativity they experienced to their work circumstances, while 14 (37%) did not feel this was the case.Three (8% ) respondents were u n decided.
S everal ad d itio n al ad m in istrativ e tasks re la te d to performance appraisal such as pre-and post-op visits, audits of files, peer reviews and 'fad-focus' activities contribute to frustrations but is not a true reflection of one's work performance.Implementation of the 'maximising performance' system is very time consuming and dividends and success appear extremely limited.

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More than half (21 ;55%) o f the participants felt that the clinical field such as scrub nurse, anaesthetic-or floor nurse, had an influence on w hether negative feelings were experienced, three (8%) respondents were undecided, while fourteen (37%) participants were o f the opinion that the clinical field made no difference to their feelings o f negativity.Frustrations experienced in all three the m entioned clinical areas are due to expectations which are not congruent with reality.

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More than half (21 ;55%) o f the participants conveyed the view that they in fact did receive adequate support and understanding from their colleagues.Fourteen (37% ) o f the respondents disagreed while three (8%) respondents were undecided.Where nurses work in fixed teams or fixed disciplines, such as orthopaedic, spinal and ophthalm ic surgery, there is a greater possibility to streamline their work, form cohesive groups and aim for perfection in service delivery.
In contrast, the self-esteem o f nurses is negatively affected when their placement in theatre is constantly changed, as they then do not appear to have the necessary accountability for a particular work station and its equipment.

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Almost three-quarters (28;74%) o f the participants stated that they did not receive adequate support from hospital management, while nine (24 %) were o f the opinion that they did receive su ffic ie n t support from h o sp ital management.One (2%) respondent was uncertain.The respondents' views are that management is removed and distant from the reality of working circumstances in theatre.Management's expectations appear to be on the increase while the staff component decreases all the time.
• More than half (20;53%) o f the participants expressed that they felt their workload was just and fair, while fifteen (39%) of the respondents disagreed, three (8%) respondents were undecided.The satisfied respondents appear to be those who p ra ctice in a d iscip lin e or environment which they favour and feel secure in.

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More than two-thirds (27;71 %) o f the participants indicated that the total workload is not justly distributed, while eight (21 %) o f the respondents disagreed and appear to be satisfied with the w o rk lo ad d istrib u tio n , three (8% ) re sp o n d en ts w ere u n d ecid ed .In allocating staff for call purposes it is not always possible to divide the workload eq u a lly am ongst all the re le v an t personnel members due to the lack of skills and experience.Which places more pressure on the skilled personnel to get the work done, and at the same time, the poorly skilled sta ff are dissatisfied because they do not benefit equally from the call allowance.

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As a lte rn a tiv e re aso n s for frustrations in the work area, almost threequarters (27;71%) o f the participants nam ed the u n a v a ila b ility o f stock (including linen) and pharmacy stock as their biggest problems.Eleven (29%) of the p artic ip a n ts did not in d icate a problem with stock.Despite many staff changes in the pharmacy store room, supposedly for improvement purposes, there remains a lack o f communication in regard o f stock required and availability on continuous bases.

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Almost two-thirds (23;61%) of the participants were o f the opinion that teamwork was not in place regarding after hours work, relief and call.Fourteen (36%) participants felt that team w ork was sufficiently in place and one (3%) o f the re sp o n d e n ts w as u n d ecid ed .The workload cannot be justly distributed in view o f relief and call purposes, because of the skill differentiation.Often it occurs that staff are trained and equipped with the necessary skills, only to lose them for better offers elsewhere.

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The greater maj ority (31; 82%) o f the participants clearly stated that they felt their remuneration was not fair in accordance with the work expected, stress levels, hours worked and responsibilities in the work area.While seven (18%) were satisfied with their rem uneration.A reason for this discontent is the fact that nurses often have to work long hours after th eir scheduled tim e, and are regularly expected to recommence the next shift early on the following day.If one accepts flexi-time when the unit is slack it often adversely affects the remuneration for a-social hours worked as overtime.

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The majority (24;63%) o f the p a rtic ip a n ts felt b u rn t out and overw orked, w hereas tw elve >(32%) seem ed to be coping.Two (5% ) respondents w ere undecided.Even though staff works a significant number o f extra hours and are subsequently tired, the flexi-time arrangements do not clearly show this and in actual fact affects the remuneration adversely.

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Three-quarters (30;79%) o f the participants were decidedly negative about the flexi-time system as it was currently practised in the unit, whereas eight (21% ) accepted the flexi-tim e arrangements.This negativity is due to the unfairness created by the flexi-time system in com parison with previous practice where nurses were remunerated for overtime in accordance with overtime rate of pay.

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The greater majority (34;90%) o f participants were strongly o f the o p in io n th at the cu rren t s ta ff establishment was inadequate to render safe and high quality patient care.Two (5% ) respondents felt that the staff establishment was adequate while two (5%) were undecided.This situation has two sides, firstly the inexperienced respondents feel resentful because the experienced staff appears reluctant to teach them, whereas the experienced staff feel extremely pressurised to carry the responsibility o f the work situation and teach sim ultaneously.D octors show resentment when the pace is delayed due to teach in g en deavours and slow learning curves.

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More than half (21 ;55%) o f the participants conveyed the view that they in fact did receive adequate support and understanding from their colleagues.F ourteen (37% ) o f the respondents disagreed, while three (7%) respondents were undecided.

Findings
From the results discussed above, the following findings are apparent:

Conclusion
In view o f many problems experienced by the nurses working in a theatre section o f a private hospital, a quantitative, exploratory and descriptive study was done to ascertain what the real reasons were for job dissatisfaction amongst these nurses.
From the findings it is evident that several factors are responsible for feelings of negativity, frustrations and burnout.These nurses work long and strenuous hours and their conditions o f service appear to have been changed unilaterally especially related to the implementation of flexi-time and overtime remuneration.It is therefore not surprising that the turnover in this unit is so extremely high.
•Dissatisfaction Dissatisfaction in terms o f this study refers to job dissatisfaction in the work environment.Job dissatisfaction is the neg ativ e attitu d e ex p erien ced by em ployees due to the way they are treated at work, their conditions o f service or the limited opportunities they are given for growth and development.