THE DETERMINANTS OF JOB SATISFACTION AMONG NURSES OF GOVERNMENT HOSPITALS: A CASE STUDY IN...

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THE DETERMINANTS OF JOB SATISFACTION

AMONG NURSES OF GOVERNMENT

HOSPITALS: A CASE STUDY IN BANGLADESH

By

Istiaq Uddin Ahmed 100207108

Prajit Barua 100207006

Md. Mahmudul Hasan 100207088

Abidur Rahman Khan 100207092

A Thesis

Submitted to the

Department of Mechanical and Production Engineering

in Partial Fulfilment of the

Requirements for the Degree

Of

BACHELOR OF SCIENCE IN INDUSTRIAL & PRODUCTION

ENGINEERING

DEPARTMENT OF MECHANICAL & PRODUCTION ENGINEERING

AHSANULLAH UNIVERSITY OF SCIENCE & TECHNOLOGY

DHAKA, BANGLADESH

October, 2014

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This project work entitled TThhee DDeetteerrmmiinnaannttss ooff JJoobb SSaattiissffaaccttiioonn aammoonngg NNuurrsseess ooff

GGoovveerrnnmmeenntt HHoossppiittaallss ((aa CCaassee SSttuuddyy iinn BBaannggllaaddeesshh)) submitted by the following students

has been accepted as satisfactory in partial fulfilment of the requirement for the degree of

B.Sc. in Industrial and Production Engineering on October 24th, 2014.

Istiaq Uddin Ahmed

10.02.07.108

Prajit Barua

10.02.07.006

Md. Mahmudul Hasan

10.02.07.088

Abidur Rahman Khan

10.02.07.092

Dr. Nikhil R. Dhar

Professor

Department of Industrial and Production Engineering

Bangladesh University of Engineering and Technology

Dhaka-1000, Bangladesh

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Declaration

We do hereby declare that this thesis work has been done by us and neither this thesis nor any part of

it has been submitted elsewhere for the award of any degree or diploma.

Istiaq Uddin Ahmed

10.02.07.108

Prajit Barua

10.02.07.006

Md. Mahmudul Hasan

10.02.07.088

Abidur Rahman Khan

10.02.07.092

Dr. Nikhil R. Dhar

Professor

Department of Industrial and Production Engineering

Bangladesh University of Engineering and Technology

Dhaka-1000, Bangladesh.

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CONTENTS

LIST OF TABLES................................................................................................... v

LIST OF FIGURES................................................................................................. vi

ACKNOWLEDGEMENT……………………………………………………….. ix

ABSTRACT ………………………………………………………..…………….. viii

Chapter 1 Introduction

1.1 Introduction ……………………………………………………… 2

1.2 Current situation………………………………………………….. 3

1.3 Literature Review………………………………………………… 5

1.4 The definition of job satisfaction……………………………….... 6

1.5 Sources of nurses job satisfaction………………………………... 7

1.6 Effects of Job satisfaction of Nurses on Absenteeism, Burnout..... 8

Chapter 2 Introduction to the Hospitals 2.1 Current Scenario of Nurses in Hospitals........................................ 11

2.2 Dhaka Medical College Hospital.................................................... 11

2.3 Acute Shortage of Nurses hinders DMCH services....................... 11

2.4 Shaheed Suhrawardy Medical College Hospital ……………….. 14

Chapter 3 Methodology 3.1 Survey……………………………………………………………. 17

3.2 Conceptual Framework………………………………………....... 18

3.3 Human Relations…………………………………………………. 19

3.4 Data Analysis…………………………………………………….. 22

3.5 Mediation by Regression with the Survey Data………………….. 22

3.6 Identification with the Interview Data…………………………… 24

3.7 Final bar chart table………………………………………………. 25

Chapter 4 work done

4.1 Herzberg’s two factor theory……………………………………... 39

4.2 Implementation of the theory…………………………………...... 40

4.3 Method………………………………………………………........ 42

4.4 Data Collection………………………………………………....... 43

4.5 Likert’s Scale…………………………………………………….. 43

4.6 Analysis………………………………………………………...... 43

4.7 Linear regression analysis………………………………….......... 46

Chapter 5 Discussion and Result ……………………………………….….. 50

Chapter 6 Conclusion and Recommendation ……………………….…….. 52

Chapter 7 References………………………………………………............. 53

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List of Tables

Table 3.1 Satisfactory levels of nurses of Nephrology Unit………………… 25

Table 3.2 Satisfactory levels of nurses of Maternity Unit…………………... 27

Table 3.3 Satisfactory levels of nurses of ICU Unit………………………… 29

Table 3.4 Satisfactory levels of nurses of Casualty Unit……………………. 31

Table 3.5 Satisfactory levels of nurses of Burn Unit………………………... 33

Table 3.6 Satisfactory levels of nurses of OPD Unit………………………... 35

Table 3.7 Satisfactory levels of nurses of all Units…………………………. 37

Table 4.1 Separation of the factors in the basis of Herzberg’s two factor

theory……………………………………………………………..

42

Table 4.2 Motivating factors influencing levels of job satisfaction………… 44

Table 4.3 Hygiene factors influencing levels of no job dissatisfaction……... 45

Table 4.4 Linear Regression Analysis of Independent variables……………. 46

Table 4.5 Standard deviation of salary of nurses……………………………. 48

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List of Figures

Fig 2.1 Dhaka Medical College Hospital……………………………….. 12

Fig 2.2 Accommodate patients who would not be allocated proper beds. 13

Fig 2.3 Shaheed Suhrawardy Medical College Hospital………………... 14

Fig 3.1 Satisfaction Framework………………………………………… 18

Fig 3.2 Interrelationship among the three domains……………………... 21

Fig 3.3 Mediators JS, NPE, QNC in the reciprocal relationship………... 22

Fig 3.4 Mediator analysis on nursing practice………………………….. 23

Fig 3.5 Satisfactory levels of nurses of Nephrology Unit………………. 26

Fig 3.6 Satisfactory levels of nurses of Maternity Unit………………… 28

Fig 3.7 Satisfactory levels of nurses of ICU Unit………………………. 30

Fig 3.8 Satisfactory levels of nurses of casualty Unit…………………... 32

Fig 3.9 Satisfactory levels of nurses of Burn Unit……………………… 34

Fig 3.10 Satisfactory levels of nurses of OPD Unit……………………… 36

Fig 3.11 Satisfactory levels of nurses of all Units……………………….. 38

VII

Acknowledgements

At the very beginning, the authors of this report wish to express their warmth

gratitude especially to the Department of Industrial and Production Engineering, AUST for

arranging this Project and Thesis Course that facilitates integration of theoretical knowledge

with practical situations.

The authors are sincerely indebted to their respected Thesis Supervisor Dr. Nikhil R.

Dhar, Professor, Department of Industrial & Production Engineering, BUET for their whole-

hearted supervision during their one year course period. His understanding, encouraging,

guidance and instructions throughout the progress of report preparing and writing have

provided a good basis for this Thesis. Without his direct help, suggestions assistance it would

be impossible to complete this work.

Finally, the authors offer their sincere thanks and apologies to several others whom

they have no doubt overlooked.

Authors

VIII

Abstract

Job satisfaction impacts on nursing staff retention. The current nursing

phenomena and high turnover in this profession is of great concern in our country. The

conflict between the organizational climate and socio economic thoughts are persistent

problems associated with job satisfaction. This paper analyses the growing literature relating

to job satisfaction among nurses and concludes that more research is required to understand

the relative importance of the many identified factors to job satisfaction. It is argued that the

absence of a robust causal model incorporating organizational, professional and personal

variables is undermining the development of interventions to improve nurse retention. The

Pediatric Nursing Certification Board surveyed a national sample of 1354 hospital-based

certified pediatric nurses [CPN] to determine their perceptions of certification on job

satisfaction and other factors. There is a substantial body of literature that demonstrates job

satisfaction among nurses positively increases retention and reduces absenteeism and burnout.

CPN seek certification for a personal sense of achievement, professional recognition, and

validation of clinical competency. The certified nurse survey respondents had self-reported

high levels of job satisfaction and indicated that relationships with colleagues and a

supportive work environment were very important to their levels of job satisfaction. The

results of this study highlight important factors for hospitals to consider as they plan strategies

and cost-effective ways to positively affect patient care and retain qualified pediatric nurses at

the bedside. Health care managers realize that job satisfaction impacts on nursing staff

retention. This study examined the job satisfaction of nursing staff [N = 30] at two

government hospitals. Just more than half of the respondents were generally satisfied.

Feelings that nursing is worthwhile and satisfying, and financial stability at the hospital could

promote staff retention.

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Chapter-1

Introduction

Job satisfaction is a multidimensional, enduring, important and much researched concept in

the field of organizational behavior [Bassett, 1994]. This is an outgrowth of the human

relations movement that began with the classic Hawthorne studies in the late 1920s.There is a

lack of Consensus as to what job satisfaction is [Hall, 1986], and how the job satisfaction of

employees should be assessed. Buss [1988], for example, described job satisfaction as an

employee’s perception that his or her job allows the fulfillment of important values and needs.

In this regard, according to Siegel and Lane [1982], motivational theories, such as equity

theory, Maslow’s need-hierarchy theory, and Herzberg’s two-factor theory, all have

substantial implications for understanding job satisfaction. A number of studies have reported

that employees who are satisfied in their job tend to stay longer in the job [Hinshaw et al

1987; Taunton et al 1989; Tett and Meyer 1993]. Research also shows that the employees

who experience job satisfaction are more likely to be productive [Cohen and Josefowitz 1980;

Likert and Katz 1979]. In 2008, the Pediatric Nursing Certification Board [PNCB] conducted

a national survey of hospital-based pediatric nurses who hold the Certified Pediatric Nurse

[CPN] credential to learn more about their perceptions of job satisfaction. The survey sought

to measure the impact of certification on job-related factors as well as those factors that

contribute to the motivation of pediatric nurses to seek certification. With responses from over

1300 certified nurses, this survey provides valuable insight into these issues from the

perspectives of hospital-based certified pediatric nurses.

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1.1 Introduction

Job satisfaction describes how content an individual is with his/her job. The happier people

are within their job, the more satisfied they are said to be. Job satisfaction is not the same as

motivation or aptitude, although it is clearly linked. Job design aims to enhance job

satisfaction and performance; methods include job

rotation, job enlargement, job enrichment and job re-engineering. Other influences on

satisfaction include the management style and culture, employee involvement, empowerment

and autonomous work position. Job satisfaction is a very important attribute which is

frequently measured by organizations. The most common way of measurement is the use of

rating scales where employees report their reactions to their jobs. Questions relate to rate of

pay, work responsibilities, variety of tasks, promotional opportunities, the work itself and co-

workers. Job satisfaction is an individual’s cognitive, affective and evaluative reactions

towards his or her job. It is the state where one’s needs and one’s outcomes match well, and a

combination of cognitive and affective reactions to the differential perceptions of what an

employee wants to receive compared to what he or she actually receives. Evidently, it is a

factor that would induce the employee to work in the long-term position, and how pleased an

employee is with his or her position of employment.

Bangladesh is a small and densely populated underdeveloped (1046/Sqkm) country with

limited natural resources. To meet the demand of these vast populations, the country’s

manufacturing and service sectors are growing tremendously. The healthcare servicing sector

is also growing as manufacturing and other service sectors. To sustain in the health market, it

is very important to provide quality service to its customers, which is achieved fruitfully when

a country could ensure the satisfaction of healthcare employees especially the nurses.

Likewise, it is also known that there is close connection between the job satisfaction of health

care staffs and the total quality of health services. Job satisfaction inhealth care workers have

a great impact on quality, effectiveness and work efficiency and at the same time on

healthcare costs. Besides its importance for patients and healthcare system as a whole,

professional satisfaction in healthcare workers indirectly connected with absence from work,

human relations and organization of work. Job Satisfaction can be an important indicator of

how employees feel about their jobs and a predictor of work behaviors such as organizational

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citizenship, absenteeism and turnover. Further, job satisfaction can partially mediate the

relationship of personality variables and deviant work behaviors. In many countries, job

satisfaction survey is regularly conducted and by monitoring obtained data, it is possible to

notice omissions in organization of work. There is a small but growing body of qualitative

studies looking at motivation of healthcare workers developing countries.

In Bangladesh, surveys on job satisfaction have been scarcely done so far. Low job

satisfaction among health providers in healthcare centre in Bangladesh is thought to be a

problem. The job satisfaction level of nurses and the relationship between job satisfaction and

socio-economic, demographic and some human resource (HR) practices have not been

performed broadly. Thus, the objectives of the study are to identify factors that contribute to

their professional satisfaction and also to fill the existing research gap. The findings of this

study would be very helpful to the health service providers and owners, to implement proper

HR strategies and policies at their organizations to ensure the satisfaction of the employees.

1.2 Current Situation

Bangladesh’s public health challenges require a skilled health care work force to provide or

improve access to quality care. Gaps in quantity and quality of nurse and midwife services

and education will have an impact on attaining the health related millennium development

goals. Health care issues, such as the increased need to deal with current and future health

effects of climate change, have merged to create the sense of urgency that now catalyzes work

to improve nursing. There is a severe shortage of nursing personnel in the country.

Bangladesh is one of a few countries in the world that has more medical doctors than nurses:

about 3 medical doctors to one nurse. Furthermore, due to the shortage of nurses and a

challenging working environment (e.g. lack of nursing equipment and effective nursing

management system), with few exceptions the quality of nursing care has been called in to

question.

Bangladesh has a number of health provider categories that provide “nursing” services. The

professional nurse in Bangladesh is currently registered as a nurse-midwife (RNM). This

registration allows for a non-specialized nurse who is generally able to be posted wherever

there may be a need. As a result, most nurse midwives do not have sufficient experience in

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midwifery to provide skilled care to women in childbirth, such care that is recognized as

being essential to MDGs 4 and 5, related to maternal and newborn health. To address these

challenges, the Government of Bangladesh (GoB) is increasing efforts to raise the image;

improve the quality of services and education; and meet the shortage of nurses and midwives.

The government has pledged to achieve these goals by:

upgrading the status of nurses and midwives

Creating midwifery posts

Establishing more nursing and midwifery educational institutions

Increasing the seats for students

Increasing capacity development of nursing and midwifery professionals

Improving the health systems that will create the positive practice environment

necessary for provision of quality nursing and midwifery services.

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1.3 Literature Review

In many medical organizations or private institutions around the world, nurses

maybe the most undervalued employees, although they are the ones who take care of us and

our loved ones in times of sickness [Masroor & Fakir, 2010]. In the medical job, nurses are

the ones who have diversified tasks and are required to take up multiple responsibilities at

their workplace, which is the hospital. However, they are still underpaid and undervalued. In

Malaysia the circumstances are no difference. According to the Malaysian Association of

Nurses, until 2009, there are no concrete plans implemented by the Government of Malaysia

to increase the motivation of nurse sing Malaysia [Masroor & Fakir, 2010]. Nevertheless, in

2008 the Malaysian Prime Minister, Abdullah Badawi saw the significance of the contribution

from nurses to the country and decided to increase the allocation in the government’s annual

budget for nurses in order to appreciate their contribution and motivate them [Masroor &

Fakir, 2010].In any industrial setting, human resources play an important role. Human

resources are organizations’ or companies’ valuable assets. Much of organizations’ or

companies’ productivity or profit relies on them. If a company’s human resources are

unmotivated or their level of job satisfaction is low, the company may face serious

productivity decline or major loss. Job satisfaction can be both intrinsic and extrinsic. Several

current scholars agree to this. This is based on the explanation that job satisfaction covers the

positive and negative emotions inside them and also the environment that they are in [Bhuian,

2002; Odon, 1990]. n Malaysia, there are 39,000 nurses and in the year 2000, the was an

average of 1.69nurses per 1,000 populations located in the low- density cluster in the world

[Masroor & Fakir,2010]. This demonstrates that Malaysia has the lower nurse density in the

area or cluster and is believed to be suffering from too much nurse migration, poor retention,

lower job satisfaction and high turnover [Casey & Fink, 2004]. However, little is known on

reasons for Malaysian nurses quitting their job. Thus, this study reviews the perceived degree

of job satisfaction and in tensions to quit amongst Malaysian nurses in relation to job

satisfaction. It is highly significant for management teams to recognize employees’ job

contentment and provide them with opportunities to develop themselves and to feel satisfied

with their job performance. Therefore, one of the most extensively studied domains in the

organizational behavior is job satisfaction [Muse & Stamper, 2007].

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1.4 The Definition of Job Satisfaction

According to Hoppock [1935], job satisfaction is a matter of national concern and

research interest. He explained that job satisfaction includes physiological, psychological and

environmental circumstances that cause an individual to say truthfully ‘I am pleased by my

position [p. 47]. Locke [1990], wrote the main review of job satisfaction, and collected

3350articles and dissertation related to this issue. Vroom and Jago [2007] indicated that the

negative attitudes toward the job corresponded to job dissatisfaction, and positive treatments

in the direction of job were conceptually similar to job satisfaction. Job satisfaction focuses on

employee’s attitudes towards their job. In other words, job satisfaction explains the factors for

individuals to be contented or discontented in their job. Job satisfaction is a topic of wide

interest to both people who work in organizations and people who study them. It is a most

frequently studied variable in organizational behavior research, and also a central variable in

both research and theory of organizational phenomena ranging from job design to supervision.

The literature relating to job satisfaction and nurses was identified through

electronic databases. The electronic databases used to obtain the relevant literature were:

CINAHL [1982–2004], Medline [1966–2004], Psyc IN-FO [1974–2004] and British Nursing

Index [1985–2004]. Some databases in Chinese such as China Medical Academic Conference

[1985–2004] and China Academic Journal [1985–2004] were also used. To maximize the

amount of relevant literature, key phrases and similar phrases were utilized in the subject

search in combination with nurses following guidelines for searching OVID interface. This

identified 1189 published research papers from all the databases searched. The abstracts or

full texts of the papers were reviewed prior to their inclusion in the literature review. One

thousand and eighty-eight papers were deemed not relevant and 47 papers were of poor

quality [research method including data analysis unclear]. Additionally, the reference lists of

the selected papers were examined to identify earlier seminal sources.

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1.5 Sources of Nurses Job Satisfaction

Given that job satisfaction has been found to be related to performance within the

work setting [Landeweerd and Boumans, 1988], it is not surprising that the concept of job

satisfaction has attracted much attention. Researchers have attempted to identify the various

components of job satisfaction, measure the relative importance of each component of job

satisfaction and examine what effect these components have on workers’ productivity

[Burnard et al., 1999]. A range of findings derived from quantitative studies as well as

qualitative studies has been reported in the literature on sources of job satisfaction among

nurses. Aiken et al. [2001] found job dissatisfaction among nurses was highest in the United

States [41%] followed by Scotland [38%], England [36%], Canada [33%] and Germany

[17%]. One third of nurses in England and Scotland and more than one fifth in the United

States planned on leaving their job within 12 months of data collection. More striking,

however, was that 27–54% of nurses less than 30 years of age planned on leaving within 12

months of data collection in all countries. Regarding the work climate, only about one third of

nurses in Canada and Scotland felt that they participated in developing their own work

schedules in comparison with more than half in the other three countries. When compared

with other countries, the nurses in Germany [61%] reported that they were more satisfied with

the opportunities for advancement while the nurses in the United States [57%] and Canada

[69%] felt more satisfied with their salaries. Some basic sources are mentioned below,

• Working conditions at which she is employed

• Interaction with the patients, co-workers, manager

• Work itself, like Workload; scheduling; challenging work; routinization; task

requirements [abilities, skills etc]

• Remuneration [pay, salary]

• Self-growth and promotion

• Professional training; opportunities of advancement; job promotion; personal

achievement

• Praise and recognition • Control and responsibility and leadership

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1.6 Effects of Job satisfaction of Nurses on Absenteeism, Burnout,

Turnover & Intention to Quit

There is an underlying supposition that lowest level of overall job satisfaction

leads to higher absenteeism; and higher level of overall job satisfaction causes lower

absenteeism [Josias, 2005; Kreitner & Kinicki, 2007]. George,Jones and Sharbrough [2008]

and Cohen and Golan[2007] maintained that several investigators have studied the association

among job satisfaction, absenteeism and intention to quit in an effort to find out the ways to

decrease turnover. Absenteeism is costly, and managers are constantly on the lookout for

ways to decrease it. One suggestion has been to increase job satisfaction. According to Scott

and Taylor [1985] the study has well demonstrated an inversely association among

absenteeism and satisfaction. In other words, when satisfaction is higher, absenteeism tends to

be lower; and when satisfaction is lower, absenteeism tends to be highest [Luthans,

1998].Absenteeism is a significant issue for health-care contributors because it is expensive

and associated to preventable work stress [Matrunola, 1996]. The effects of job satisfaction

leadingto burnout, absenteeism and intentions to leave among nurses and turnover rate have

been investigated in several studies, but the findings are ambiguous. Matrunola [1996] found

that there was no association among absenteeism and job satisfaction among the English

nurses that he studied. A research administered by [Yunus, 2009] in public hospitals in the

northern states of Malaysia. The samples of 2400 nurses from the medical and maternity ward

from a target population of 3000 nurses employed in four hospitals were collected. The

findings of the research demonstrated that there was a relationship between work overload

and emotional exhaustion, and there was also a relationship among the role overload and

burnout. It is particularly remarkable that nurses who have experience a high job stress shows

low cognitive empathy and empowerment, and works on night shifts at hospitals are more

likely to experience burnout. Cavanagh & Coffin [1992] indicated that job satisfaction and

participation at work to be significant variables in the turnover procedure. Yin and Yang’s

[2002] meta-analysis also indicated that the strong human being and organizational factors

correlated to nursing turnover were job satisfaction, advancement opportunity, pay,

autonomy, marital status, job stress and group cohesion.

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1.7 Related Factors to the Job Satisfaction of Nurses

Job satisfaction is a multifaceted phenomenon. The recognition of this fact and the

investigation done on it provide the possibility for the researcher to refine the hypothetical

models of nurses’ job satisfaction and help to minimize manager’s interferences [Blegen,

1993].Blegen [1993] explained that job satisfaction is most strongly related with

organizational commitment and stress. Job satisfaction is associated with depression,

subjective stress, hostility; intensity of stressful events, frequency of stressful events and

anxiety. Organizational commitment, or employee loyalty, is the level to which an employee

identifies with the organization and desires to maintain active participation in it. Mowday,

Steers and Porter [1979] concluded that organizational commitment was the intensity of

identification an employee received from their organization. Organizational commitment is

the intensity of an employee’s identification with and participation in a specific organization,

including “[a] a definite desire to retain the organizational membership [b] a strong belief in

and acceptance of the organization’s goals and values [c] a willingness to exert considerable

effort on behalf of the organization” [Porter, Steers, Mowday, & Boulian, 1974]. Many

researchers have found that organizational commitment has been positively associated with

job satisfaction among hospital nurses [Al-Aameri, 2000; Blegen, 1993]. Knoop [1995]

indicated that organizational commitment was associated with overall job satisfaction

promotion opportunity, and satisfaction with work, pay, co-workers and supervision among

the Canadian nurses that he studied. Based on the study by Masroor & Fakir [2010], it was

found that nurses studied were moderately satisfied with their job. This study was conducted

among 153 nurses from the state of Perlis. The study looked at six aspects of job satisfaction

which were satisfaction with compensation, HRM/management policies, supervisor, closure,

job variety and co-workers.

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1.8 Strategies to Minimize Nurse’s Turnover & Increase Nurse’s Job

Satisfaction

Among the strategies that can be employed to reduce nurses’ turnover was to

change policies on recruitment, training, selection, induction, job design and salary payment

[Ongori, 2007]. Besides that, achieving better understanding of the factors associated with

recruitment, motivation and maintenance of nurses was crucial in deterring nurses’ turnover

[Bartram, Joiner,& Stanton, 2004; Coomber & Louise Barriball, 2007]. Other than these,

ensuring high level of job satisfaction, organizational commitment and career satisfaction is

essential in minimizing nurses’ turnover. This is because high level of satisfaction reflects

positive feelings towards the organization, thus having a direct influence on nurse’s intent to

quit.

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Chapter-2

Introduction to The Hospitals

2.1 Current Scenario of Nurses in Hospitals

We mainly worked with Bangladesh’s two renowned hospitals such as Dhaka

Medical College Hospital and Shaheed Suhrawardy Medical College Hospital. We have

surveyed around 30 nurses of these two hospitals. Between these two separate working

environments nursing job satisfaction varies. But some common problems exist between both

of the nurse’s in those hospitals. Firstly we can look on to the current scenario two of the

hospitals.

2.2 Dhaka Medical College Hospital

Dhaka Medical College and Hospital (DMCH), was established in 1946 during

the British colonial rule. Since its establishment, Dhaka Medical College is continuously

playing a pioneering role in dispersing medical education among young pupils. The hospital

attached with the college provides affordable health care to a huge number of patients through

its outdoor, indoor and emergency facilities

2.3 Acute Shortage of Nurses Hinders DMCH Services

Around 30,000 nurses were working in the private sector because the pay is

better but in the public hospital scenario is different. Here, Ward patients got ready for a

routine dose of medicine in Dhaka Medical College Hospital (DMCH). But the only nurse on

duty was nowhere to be found. Time ticked on and eventually all the patients got late for their

doses. A little later, the senior staff nurse in charge of the ward was found surrounded by

attendants and relatives of patients. She could not come on her routine visit because she was

busy serving them. There were supposed to be three nurses for looking after the patients in

12

this ward, but the only nurse available at the time. Some of the patients and their attendants

said it’s not just for a particular ward, but almost none of the wards at the DMCH have the

required number of nurses. So definitely there is a huge shortage of nurses. Assistant director

of the Directorate of Nursing Services said nurses at the DMCH had to attend 20 to 25

patients at a time while the standard nurse to patient ratio is 1:5 at best. Acute shortage of

nurses was not only affecting the DMCH but also all the other public healthcare facilities in

the country. At least 2,000 posts are vacant out of the 17,000 designated posts at the various

government facilities. The government has increased the number of beds at upazila and

district levels but left the number of nurses the same.

Fig 2.1 Dhaka Medical College Hospital

Around 2,300-bed DMCH is the biggest public hospital in the country where around 2,500

patients on an average come for treatment every day. In 1984, DMCH was an 800-bed

hospital with around 600 nurses. In about three decades, the number of beds had increased

nearly three times, in phases. . But the number of nurses remained at 600, of which 90% are

13

female; hospital sources said nursing superintendent of DMCH, said the daily workload on

each nurse was inhuman. Attending more than 20 patients, push saline, injections and give

medicines, collect blood and other samples for pathological tests, sending the reports to the

doctors, maintaining register books, and so on. Often the nurses have to carry out the

additional duties of a doctor, a ward boy and also those of the sweeper at crunch times. In

developed countries nurses are looking after just one patient. We do not want that much but at

least we can expect the minimum number of nurses to run a ward. DMCH Director Brigadier

General Mustafizur Rahman said: “The severe shortage of nurses is a big problem for such a

huge hospital, especially, with the immense pressure of patients. He said the hospital

authorities were trying really hard to provide the best possible services with limited

manpower. Asaduzzaman Jewel, an ex-officio of Bangladesh Diploma Nurses Association,

said the health ministry had created 4,744 new posts at public hospitals and would recruit

2,300 nurses by 2014. However he said the he process had been going forward very slowly.

Fig 2.2 Accommodate patients who would not be allocated proper beds

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2.4 Shaheed Suhrawardy Medical College Hospital

Shaheed Suhrawardy Medical College was inaugurated on 6th May, 2006. It is the

14th Government Medical College in Bangladesh. This medical college is situated in the

‘Zone of Medical Institution’ at Sher-E-Bangla Nagar, Dhaka. The government set up the

college to spread medical knowledge and to produce more efficient doctors for the country.

Fig 2.3 Shaheed Suhrawardy Medical College Hospital

15

2.5 Shaheed Suhrawardy Medical College Hospital Limping Along on

Limited Facilities

We have found in The Daily Star that a patient who had suffered a head injury

were crying helplessly at the emergency ward of Shaheed Suhrawardi Hospital in the city

where the attending doctor and nurses did not do anything except referring the patient to

Dhaka Medical College and Hospital (DMCH). They even did not provide any primary

treatment to the patient who needed at least half an hour or more to take him to the DMCH,

said the scared brother of the patient. This patient fell from an under-construction building at

Mohammadpur area and received severe injury in his head. As the Suhrawardi Hospital is

nearer to Mohammadpur, the relatives brought him to that hospital for quick treatment, but it

only led to his delayed treatment. A significant number of patients who seek treatment at the

emergency department of the hospital are referred to other hospitals, as the hospital is yet to

be equipped with full- fledged emergency service facilities. “Every day on an average some

30 to 100 patients who seek treatment here are referred to different hospitals as we don't have

enough facilities for treating them,” said the on-duty Emergency Medical Officer Dr Saiful.

“As we don't have any CT scan machine here, we cannot provide service for patients with

head injury. At the same time, due to lack of Intensive Care Unit (ICU) we have to refer them

to other hospitals,” he said, adding, “We just give primary treatment to the patients, and if

necessary, we admit them to this hospital.” But as there is no casualty, neurosurgery,

neurology, paediatric surgery and cardiology departments, the hospital has to send back these

patients without considering whether their condition is critical or not, he added. It is also

surprising that no emergency operation takes place in the 375-bed public hospital except the

delivery for lack of manpower and surgical instruments. Shortage of medicine at the hospital

also leads to continuous sufferings of the poor patients, and often the hospital can supply only

10 types of medicine at a time although it should have more than 70 types of drugs, sources

said. Other facilities also were not expanded although the inflow of patients increased a lot in

last few years. The bed occupancy at indoors increased from 73.92 percent to 76.91 percent in

2005 and 2006, which was mounted to 87.36 percent in 2008. But the number of doctors has

not been increased since last 10 years. A total of 192 doctors, nurses and class three and class

four employees were recruited in 1997 and then some class three and class four employees

16

were recruited in 2004, and since then no recruitment was made. At present the hospital is

running with 97 doctors and 172 nurses. A large number of patients waiting since 9:00am, but

they were yet to get the serial. “Every day nearly 400 patients come for treatment at the

outdoor department of medicine ward, but there are only four doctors to attend them. It is not

possible for a doctor to treat a hundred patients from 8:00am to 1:00pm,” said the on-duty

doctor. The pressure of the patients has been rising day by day in the hospitals, especially

after its turning into a medical college in 2005. From this above situation we can come to a

solution that a hospital where facility is limited how one can expect better treatment as well as

where nurse patient ratio is too big how they will provide better health care for patients.

Nurses are facing huge workload on the time of treating patient but the hospital authority

could not able to fulfill their satisfactory needs. In this weird situation Government should

take proper steps to minimize this problem. Nurses will be motivated to the private hospital

rather than public hospitals. So the general people will be threatened by this poor condition of

public hospitals.

17

Chapter-3

Methodology

Methodology is the systematic, theoretical analysis of the methods applied to a field

of study. It comprises the theoretical analysis of the body of methods and principles

associated with a branch of knowledge. Typically, it encompasses concepts such as paradigm,

theoretical model, phases and quantitative or qualitative techniques.

Here we have discussed about survey, conceptual framework, human relations for

healthy nursing practice environment, nurses job satisfaction and quality of nursing care and a

bar chart for overall survey findings.

3.1 Survey

The survey included questions about staff characteristics [education, experience and

gender], work schedules [shift and hours worked], perceptions about level of staffing,

satisfaction with current position [referring to where the respondent is currently working] and

satisfaction with being a nurse, a nurse assistant or a unit secretary [occupation]. Responses

were made on a scale ranging from 1 [dissatisfied] to 3 [satisfied]. Nursing staff also indicated

how many patients they cared for on the previous shift they worked. Other demographic data

collected were education [highest degree earned], age, gender, years of experience in role,

work schedule [shift worked, part-or full-time] and overtime [number of overtime hours in the

past 3 months].We divided our survey questions in six categories which are socio-

demographic data, job satisfaction subscale, job oriented information, equipment & resources,

safety related information and considerations. We conducted our survey in five different units

in two hospitals. The units are OPD [outpatient department], burn unit, casualty unit, ICU

18

[intensive care unit], maternity unit. Some of the nurses were surveyed directly by us and we

help them to understand the questions. And the survey questions were distributed among the

other nurses and those were collected lately. After some days we got survey results of 30

different nurses.

3.2 Conceptual Framework

In the present study, the independent variables were nurse and unit characteristics

and teamwork and the dependent variables were staff satisfaction with current position and

with occupation. The framework presented in Figure 1 hypothesizes that individual nursing

staff characteristics [i.e. gender, experience, education, hours worked per week, shift worked

and role] and patient unit characteristics [i.e. type of unit, perceived staffing adequacy and the

number of patients cared for on previous shift] and teamwork influences the level of job

satisfaction. Outside of healthcare research has shown significant positive relationships

between age and job satisfaction [Rhodes 1983, Lee 1985, Schwo-erer & May 1996], tenure

[Clark 1997] and gender [Clark 1997]. Studies have also demonstrated that staffing levels are

associated with nursing staff job satisfaction [Aiken et al. 2002, 2003]. Previous studies

within nursing, as described above, and outside of nursing and healthcare have suggested that

higher teamwork leads to greater job satisfaction [Griffin et al. 2001, Valle & Witt 2001,

Mierlo et al. 2005].

Nursing characteristics Satisfaction with

Gender occupation Age Education Years of experience Job title Satisfaction with Unit characteristics

Unit type Current position Perceived staffing adequacy Number of patients cared for

Fig 3.1 Satisfaction Framework

19

3.3 Human Relations for Healthy Nursing Practice Environment, Nurses

Job Satisfaction and Quality of Nursing Care

Relationship between the three domains of nursing practice environment, nurses’

job satisfaction and quality of nursing care have been studied for a way forward to superior

healthcare delivery. The research result identified interactions between nurses as a vehicle

through which the reciprocal relationship between the domains are kept in motion. While

healthy interactions between nurses that generate trust and gratitude were seen to positively

impact the domains, the opposite was noticed in case of unhealthy interactions. Therefore,

management practices in nursing administration should invest for healthy human relations to

achieve enhancements across the three domains. Nursing practice environment represents the

structure and process that can lead to the outcomes of nurse’s job satisfaction and quality of

nursing care. One of the valuable insights from these literatures is that, changes in the nursing

practice environment could bring desirable positive outcomes in nurse’s job satisfaction and

quality of nursing care. Nonetheless, the existing literature analyses the relationship between

the three domains of nursing practice environment, nurse’s job satisfaction and quality of

nursing care as one-directional, rather than considering the possibility of “reciprocity” of

directions that might exist. The term “reciprocity” here is referring to the mutual dependence

of the three domains, that is, how each of these domains are impacting each other and

mutually dependent on each other. Organizational determinants of work outcomes and quality

care ratings among Army Medical Department registered nurses reported that nurses in an

unfavorable nursing practice environment are 11 times more likely to deliver fair to poor

quality of care. However, there were no reporting of how the delivery of fair to poor quality of

care might also impact on nurses’ job satisfaction and work environment. In fact, the author of

this paper conducted a literature search from 1999 until February 2010 and failed to arrive at

any paper that studied the three domains of nursing practice environment, nurses’ job

satisfaction and quality of nursing care in reciprocal directions. It seems that changes in the

nursing practice environment are drawn, without a comprehensive view of how each of the

domains can affect each other. A symptom in this regard is nurses are reported to believe,

changes in health care system will worsen the timeliness, effectiveness and efficiency aspects

of patient care. Despite constant restructuring in the health system, substantial portion of

20

nurses are still facing verbal abuse (56%), hostility at workplace (24%) and physical injuries

(38%). Hence, there is a need to learn how to achieve improvements across the three domains

of nursing practice environment, nurse’s job satisfaction and quality of nursing care. A step

towards that learning can be to comprehend the reciprocity between the three domains,

especially for its human relations aspect. The purpose of this paper is to draw insight for

possible reciprocal relationships between the three domains of nursing practice environment,

nurse’s job satisfaction and quality of nursing care. Although this insight is not an innovation,

given the background in the previous paragraphs, it is believed that the insight is certainly not

we articulated and practiced in nursing management. The research question that the paper

addresses is:

“How are the domains of nursing practice environment, nurse’s job satisfaction and

quality of nursing care interrelated?”

The paper will approach the research question with mixed methods, including a survey

questionnaire and one-on-one interviews. Data from the survey is expected provide a

quantitative picture of the possibility of a reciprocal relationship between the domains. The

interviews will search for insights of human relations aspect in answering the research

question. That is, whether they lived experiences of interaction between nurses (e.g. nursing

administrators, nurse managers, nurse clinicians, new graduate registered nurses) in the

workplace could provide an insight behind the proposed interrelationship of the domains.

Such research can contribute to fill the scarcity of reciprocal study between the domains in the

literature. It has the potential to generate interest for investing behind human relations, as a

gateway towards healthy nursing practice environment, nurse’s job satisfaction and quality of

care.

The following section briefly describes the three domains, along with the importance of

studying the interrelationship between the domains. Such information is pivotal to the

conceptual framework of this paper.

The importances of studying the interrelationship between the domains are as follows:

21

3.3.1 Nursing Practice Environment: The nursing practice environment is referring to

nurses’ work context which is represented through organizational characteristics such as

staffing and resource adequacy, nurse manager ability, nurse participation in hospital affairs,

nursing foundation for quality of care, nurse-doctor relationship and cultural values.

3.3.2 Nurses’ Job Satisfaction

The domain can be defined as reaction to job from different perspectives such as

emotional assessment, evaluation of attitude, expectation gap and appraisal of belief system.

In this paper, job satisfaction is accepted as a contented emotional state that results when one

is achieving the desired job values.

3.3.3 Quality of Nursing Care

The quality of nursing care domain is perceived as the degree to which the nurses’

initiatives meet the individual need of patients. An examination of quality of nursing care

might involve assessment of the structures, processes and outcomes that meets patient needs

for technical care, as well as the interpersonal relationship with nurses. The importance of

studying the association between the above mentioned three domains.

Fig 3.2: Interrelationship among the three domains.

22

3.4 Data Analysis

This section will explain how to study how the domains of nursing practice

environment, nurse’s job satisfaction and quality of nursing care are affecting each other.

There are two parts in this section, the first part explains the quantitative analysis technique of

mediation by regression and the next part is about the qualitative analysis of theme

identification.

3.5 Mediation by Regression with the Survey Data

The mediator analysis technique was applied to learn about the possibility of

reciprocity between the three domains of nursing practice environment, nurse’s job

satisfaction and quality of nursing care. A mediator works as the mechanism through which

the independent variable can exert full or partial influence on the dependent variable. Each

domain was analyzed for its role as a mediator, between the reciprocal relationships of the

other two domains. The combined results of the mediator analysis of each of the domains of

nursing practice environment, nurse’s job satisfaction and quality of nursing care, as shown in

Figure, can reveal whether there is reciprocity when the three domains are put in relationships

at once. Only detailed explanation of the mediating role of the nursing practice environment is

provided here, since the steps are exactly the same for all of the three domains. In this

analysis, the task was to assess whether nursing practice environment can influence the

reciprocal relationship between nurses’ job satisfaction and quality of nursing care. Mediation

analysis was as indication of a role of nursing practice environment that influenced the

association between job satisfaction and quality of nursing care. The following Figure depicts

the regression steps for the mediator analysis on the domain of nursing practice.

Fig 3.3: Mediators JS, NPE, QNC in the reciprocal relationship.

http://pubs.sciepub.com/ajnr/1/1/2/#Figure2

http://pubs.sciepub.com/ajnr/1/1/2/#Figure2

23

The analysis ran three regressions as shown below]. The first was between nurses’ job

satisfaction and nursing practice environment, to test the influence of nurse’s job satisfaction

towards the possible mediator nursing practice environment. The second had nurses’ job

satisfaction as an independent domain impacting the domain of quality of nursing care. Then

the third and the last one had two independent domains, nurses’ job satisfaction and nursing

practice environment, impacting on the dependent variable of quality of nursing care. In order

to capture the mediating role of nursing practice environment, between nurse’s job

satisfaction and quality of nursing care from both directions, another three regressions were

run again. Nursing practice environment can be a mediator if four conditions are met: first

one, nurse’s job satisfaction and quality of nursing care are found to have a significant

influence on nursing practice environment in the first regressions; second one, nurse’s job

satisfaction and quality of nursing practice environment are found to be significant influencers

to each other in the second regressions. third one, the third regressions show nursing practice

environment to be a significant influencer to quality of nursing care and nurses’ job

satisfaction and lastly, the third regressions show reduction in the degree to which nurses’ job

satisfaction and quality of nursing care impact on each other in comparison to that of the

second regression. It is preferred to learn more of nursing practice environment’s role as a

mediator, from nurses’ real life experiences to be collected during interviews. Literature

suggests that combination of quantitative and qualitative information can provide greater

insights into mediation relations.

Fig 3.4: Mediator analysis on nursing practice

24

3.6 Identification with the Interview Data

Themes were identified when discussions reflected intense and recurrent feelings

in an interviewee. For example intense feeling was noticed, when an interviewee expressed

frustration in situations when nurse administrators roll out impractical changes in the

workplace. This feeling had intensity, as it reflected the interviewee’s desire for greater

control and respect in her job. Moreover, the interviewee had expressed such feeling of

frustration frequently while describing interactions with nursing administrators in the work

environment. Thus, a theme was coded as “interaction with nursing administrators”. Codes

such as “interaction with nursing administrators” were considered provisional at this stage.

Three themes were finalized in relevance to the research question in this paper. These are;

one, interaction between nurse managers and nurse clinicians, two, interaction with new

graduate registered nurses and three, interaction with nursing administrators. Nurse Managers

refer to nurses working in the role of unit manager, while the nurse clinicians include nurses

in classifications of registered/bedside nurses, clinical nurse specialists, clinical nurse

educators and clinical nurse consultants. The new graduate registered nurses refer to fresh

graduates from the University. Lastly, the nursing administrators relate to nurses working at

higher organizational level.

Finally, Nursing practice environment, nurse’s job satisfaction and quality of nursing care are

three important domains of nursing work life. As nurses interact with each other to deliver

patient care, they also experience an interrelationship between these three domains. The

human relations aspect in the interrelationship between the three domains makes it apparent

that initiatives in one domain will inherently impact the others. Therefore, management

practices in nursing administration cannot be compartmentalized, into any one of the domains.

Investment in human relations seems to be the key to achieve benefits across the three

domains. Given the understanding that unhealthy interaction between nurses can create

mistrust and jeopardize progress in the three domains (i.e. nursing practice environment,

nurse’s job satisfaction and quality of nursing care), there is little doubt to the merit of such

investment.

25

3.7 Final bar chart table

Number of Criteria: 1. Satisfied (S)

2. Dissatisfied (D)

3. No comments (N)

Number of Sample: 30

Result of survey for Nephrology unit

Table 3.1: Satisfactory levels of nurses of Nephrology Unit

Above table represents the satisfactory levels of nurses of nephrology unit. We have found the

nine main factors from the survey question answers from nurses and we divided the results in

three criteria which are satisfied, dissatisfied and no comments. We took the answers from

nurses to rate the factors and to find different results for nine different factors.

Serial

Number

Salary Incentive Working

Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety &

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 D D S D S S D D D

2 D N S S S N N S D

3 S S D N N S D S D

4 S S S D D D D S S

5 S S N D S D D N S

26

Fig. 3.5: Satisfactory levels of nurses of Nephrology Unit

From the table of satisfactory levels of nurses of Nephrology Unit we constructed a graphical

representation. This graph shows the number of persons answering with satisfied, dissatisfied

and no comments for the nine different factors. And from this graph we can assume the most

important factors according to the nurses.

0

0.5

1

1.5

2

2.5

3

3.5

4

Satisfied

Dissatisfied

No Comments

27

Result of survey for Maternity unit

Table 3.2: Satisfactory levels of nurses of Maternity Unit

Above table represents the satisfactory levels of nurses of maternity unit. We have found the




Serial

Number


Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety &

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 S S D D N D D S D

2 S S S S D D S N D

3 D D N D S S D S D

4 D N S N D D D N N

5 N N D S D D D S S

28

Fig. 3.6: Satisfactory levels of nurses of Maternity Unit

From the table of satisfactory levels of nurses of maternity unit we constructed a graphical




0

0.5

1

1.5

2

2.5

3

3.5

4

Satisfied

Dissatisfied

No Comments

29

Result of survey for ICU unit

Table 3.3: Satisfactory levels of nurses of ICU Unit

Above table represents the satisfactory levels of nurses of ICU unit. We have found the nine

main factors from the survey question answers from nurses and we divided the results in three

criteria which are satisfied, dissatisfied and no comments. We took the answers from nurses to

rate the factors and to find different results for nine different factors.

Serial

Number


Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety

&

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 S S S D D D D S N

2 S S D S N D D S D

3 D D S D S N S D N

4 N N D N S S D S S

5 D D D D D D D S D

30

Fig 3.7: Satisfactory levels of nurses of ICU Unit

From the table of satisfactory levels of nurses of ICU unit we constructed a graphical




0

0.5

1

1.5

2

2.5

3

3.5

4

Satisfied

Dissatisfied

No Comments

31

Result of survey for Casualty unit

Table 3.4: Satisfactory levels of nurses of Casualty Unit

Above table represents the satisfactory levels of nurses of casualty unit. We have found the




Serial

Number


Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety

&

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 D D N S D D D S D

2 S S D D S D D S S

3 D D S S D D N S D

4 D N D D D S D D S

5 N N S S D D D S D

32

Fig 3.8: Satisfactory levels of nurses of Casualty Unit

From the table of satisfactory levels of nurses of casualty unit we constructed a graphical




0

0.5

1

1.5

2

2.5

3

3.5

4

Satisfied

Dissatisfied

No Comments

33

Result of survey for Burn unit

Table 3.5: Satisfactory levels of nurses of Burn Unit

Above table represents the satisfactory levels of nurses of burn unit. We have found the nine




Serial

Number


Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety

&

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 D D S D S S S S D

2 N N N D N S N S D

3 D S S S D S N S S

4 D N D N D S D S D

34

Fig. 3.9: Satisfactory levels of nurses of Burn Unit

From the table of satisfactory levels of nurses of burn unit we constructed a graphical




0

0.5

1

1.5

2

2.5

3

3.5

4

Satisfied

Dissatisfied

No Comments

35

Result of survey for OPD unit

Table 3.6: Satisfactory levels of nurses of OPD Unit

Above table represents the satisfactory levels of nurses of OPD unit. We have found the nine




Serial

Number


Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety

&

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

1 D D D D D D D S D

2 S S S S S S D S D

3 D N D D N N N S D

4 N S S N S D S S D

5 D D N D D D S S N

6 S S D S N D D S N

36

Fig. 3.10: Satisfactory levels of nurses of OPD Unit

From the table of satisfactory levels of nurses of OPD unit we constructed a graphical




0

1

2

3

4

5

6

Satisfied

Dissatisfied

No Comments

37

Overall Bar Chart Calculation:

Table 2.7: Satisfactory levels of nurses of all units

In this table the total number of nurses given the answers satisfied, dissatisfied and no

comments are shown. It was considered for all the units together. So here the answers of the

nurses are divided in three criteria for nine different factors. And from this table we came to

know about satisfaction or dissatisfaction level of nurses for each of the factors.

Criteria Salary Incentive Working

Environment

Distributed

Responsibilities

& Time

Social

Acceptance

Safety

&

Security

Feedback

from

Authority

Equipment

Facility

Staffs &

Resources

Satisfied 10 12 13 10 10 10 5 24 7

Dissatisfied 15 9 12 15 14 17 20 3 18

No

Comments 5 9 5 5 6 3 5 3 5

38

Fig. 3.11: Satisfactory levels of nurses of all units

This graph shows the total number of satisfied or dissatisfied nurses according to the nine

different factors.

From this above Bar Chart we have found five most critical points:

1. Salary

2. Distributed Responsibilities & Time

3. Safety & Security

4. Feedback from Authority (Most critical)

5. Staff and resources

0

5

10

15

20

25

Satisfied

Dissatisfied

No Comments

39

Chapter-4

Work Done

4.1 Herzberg’s two factor theory

The two-factor theory (also known as Herzberg's motivation-hygiene theory

and dual-factor theory) states that there are certain factors in the workplace that cause job

satisfaction, while a separate set of factors cause dissatisfaction. It was developed by

psychologist Frederick Herzberg, who theorized that job satisfaction and job dissatisfaction

act independently of each other.

job characteristics related to what an individual does — that is, to the nature of the work one

performs — apparently have the capacity to gratify such needs as achievement, competency,

status, personal worth, and self-realization, thus making him happy and satisfied. However,

the absence of such gratifying job characteristics does not appear to lead to unhappiness and

dissatisfaction. Instead, dissatisfaction results from unfavorable assessments of such job-

related factors as company policies, supervision, technical problems, salary, interpersonal

relations on the job, and working conditions. Thus, if management wishes to increase

satisfaction on the job, it should be concerned with the nature of the work itself — the

opportunities it presents for gaining status, assuming responsibility, and for achieving self-

realization. If, on the other hand, management wishes to reduce dissatisfaction, then it must

focus on the job environment — policies, procedures, supervision, and working conditions. If

management is equally concerned with both, then managers must give attention to both sets of

job factors. Herzberg's theory concentrates on the importance of internal job factors as

motivating forces for employees. He designed it to increase job enrichment for employees.

40

Herzberg wanted to create the opportunity for employees to take part in planning, performing,

and evaluating their work. This theory distinguishes their working behavior, conditions,

nature and possible characteristics to improve experience.

Two-factor theory distinguishes between:

Motivators (e.g. challenging work, recognition, responsibility) give positive satisfaction,

arising from intrinsic conditions of the job itself, such as recognition, achievement, or

personal growth.

Hygiene factors (e.g. status, job security, salary, fringe benefits and work conditions) do not

give positive satisfaction, though dissatisfaction results from their absence. These are extrinsic

to the work itself, and include aspects such as company policies, supervisory practices, or

wages/salary.

Essentially, hygiene factors are needed to ensure an employee is not dissatisfied. Motivation

factors are needed to motivate an employee to higher performance. Herzberg also further

classified our actions and how and why we do them, for example, if you perform a work

related action because you have to then that is classed as "movement", but if you perform a

work related action because you want to then that is classed as "motivation"

4.2 Implementation of the theory in our analysis

Job satisfaction is an essential element for the maintenance of the workforce of

any organization. Lack of job satisfaction for employees not only leads to high turnover

rates but could also have detrimental effects on the individual. A high turnover rate leads

to the inability of an organization to provide quality care, raises personnel recruitment,

selection and orientation costs, and lowers employee’s job satisfaction levels Herzberg’s

Theory of Motivation was used as the theoretical framework for this study. This theory

postulates that intrinsic and extrinsic factors enable individuals to satisfy their personal needs

and experience job satisfaction in a work environment (Ball, 2003). Herzberg’s Theory of

Motivation postulates that the phenomenon of job satisfaction and/or no satisfaction, is the

function of two need systems, namely, extrinsic or hygiene and intrinsic or motivation factors.

These two groups of factors enable employees to avoid unpleasant situations and discomfort

41

and to meet their personal development needs. According to Daft (2000:540), Herzberg

maintains that an individual’s attitudes to work can determine his/her successes or failures in

fulfilling specific roles. Herzberg studied “what do people want from their jobs?” He asked

people to explain situations where they felt good or bad in relation to their jobs. These results

were categorized as extrinsic and intrinsic factors related to job satisfaction. Extrinsic

(hygiene) factors relate to no job satisfaction including supervision, company policy and

administration, working conditions and interpersonal relations. Poor hygiene factors increase

employees’ levels of no satisfaction. However, good hygiene factors do not improve job

satisfaction but simply reduces levels of no job satisfaction.

Intrinsic factors (motivators) include achievements, recognition, work itself,

advancement, responsibility and growth. These factors influence job satisfaction. Without

motivators, employees become neutral towards their jobs. The presence of motivators

increases the job satisfaction levels. Therefore intrinsic factors (motivators) focus on job

satisfaction and extrinsic (hygiene) factors focus on no job satisfaction factors. Herzberg’s

theory’s constructs indicate that once the hygiene factors are properly addressed, the

motivators will promote job satisfaction and productivity.

In our survey questions we asked a question about the numbering the factors serially that

affect their job satisfaction from the most to the least. And from there we divided the 9 factors

in two types which are shown below. We found four motivating factors and five hygiene

factors.

42

Table 4.1: Separation of the factors in the basis of Herzberg’s two factor theory

Intrinsic factors

We found five motivating or intrinsic factors which are salary, distributed

responsibilities and time, staffs and resources, safety and security, incentive. That means these

are the factors which affect the most in job satisfaction level of nurses.

Extrinsic factors

We found four hygiene or extrinsic factors which are working environment,

feedback from authority, social acceptance and equipment facility. These are the factors that

affect not on dissatisfaction but on no job dissatisfaction.

4.3 Method

This study used a quantitative exploratory descriptive design to identify and

describe factors that influence nurses according to their job satisfaction level. Herzberg’s

Theory of Motivation was used as a conceptual framework for collecting and analyzing data.

The identified factors were categorized as extrinsic and intrinsic factors influencing nurse’s

job satisfactions.

Intrinsic(motivating)factors focusing on

job satisfaction

Extrinsic(hygiene) factors focusing on no

job satisfaction

Salary working environment

Distributed responsibilities and time Feedback from authority

Staffs and resources Social acceptance

Safety and security Equipment facility

Incentive

43

4.4 Data collection

Self-completion questionnaires were used to obtain data relevant to the study in

order to answer the research questions. All 30 professional nurses employed by the two

randomly selected hospitals, received questionnaires. The questionnaire wad formulated in the

basis of MMSS (mccloskey mueller satisfaction scale) and Likert’s scale.

4.5 Likert’s scale

A Likert scale is a psychometric scale commonly involved in research that

employs questionnaires. It is the most widely used approach to scaling responses in survey

research, such that the term is often used interchangeably with rating scale, or more accurately

the Likert-type scale, even though the two are not synonymous. Likert distinguished between

a scale proper, which emerges from collective responses to a set of items (usually eight or

more), and the format in which responses are scored along a range. After the questionnaire is

completed, each item may be analyzed separately or in some cases item responses may be

summed to create a score for a group of items

4.6 Analysis

Data analysis commenced after no further completed questionnaires had been received

for three successive weeks. The total number of questionnaires used in the data analysis was

30, but not all totals add up to 30 as some respondents failed to complete specific items. Data

from the questionnaires were statistically analyzed using the Microsoft Excel computer

program. Please note not all respondents answered every question, consequently the total

number of responses to specific items vary and does not always add up to 30. The percentages

were calculated based on the number of responses to individual items.

http://en.wikipedia.org/wiki/Psychometrics

http://en.wikipedia.org/wiki/Questionnaire

http://en.wikipedia.org/wiki/Rating_scale

44

Table 4.2: Motivating factors influencing levels of job satisfaction

Dissatisfaction Motivating factors Satisfaction

58% Salary 42%

72% Distributed responsibilities

and time

28%

71% Staffs and resources 29%

61% Safety and security 39%

40% Incentive 60%

We calculated the percentage of satisfaction and dissatisfaction individuals according to the

five motivating factors that we have found in the above table.

45

Table 4.3: Hygiene factors influencing levels of no job dissatisfaction

Dissatisfaction Motivating factors Satisfaction

58% Salary 42%

72% Distributed responsibilities

and time

28%

71% Staffs and resources 29%

61% Safety and security 39%

40% Incentive 60%

We calculated the percentage of satisfaction and dissatisfaction individuals according to the

four hygiene factors that we have found in the above table.

We divided all the important factors of job satisfaction level of nurses in two categories which

are motivating and hygiene factors. So now we can make decision which factor is needed to

be full filled first. We also can differentiate the factors according to their importance

46

4.7 Linear regression analysis

Regression analysis is a statistical process for estimating the relationships among variables. It

includes many techniques for modeling and analyzing several variables, when the focus is on

the relationship between a dependent variable and one or more independent variables. More

specifically, regression analysis helps one understand how the typical value of the dependent

variable (or 'criterion variable') changes when any one of the independent variables is varied,

while the other independent variables are held fixed. Most commonly, regression analysis

estimates the conditional expectation of the dependent variable given the independent

variables – that is, the average value of the dependent variable when the independent variables

are fixed. Less commonly, the focus is on a quintile, or other location parameter of the

conditional distribution of the dependent variable given the independent variables. In all

cases, the estimation target is a function of the independent variables called the regression

function. Regression analysis is widely used for prediction and forecasting, where its use has

substantial overlap with the field of machine learning. Regression analysis is also used to

understand which among the independent variables are related to the dependent variable, and

to explore the forms of these relationships. In restricted circumstances, regression analysis can

be used to infer causal relationships between the independent and dependent variables.

However this can lead to illusions or false relationships, so caution is advisable

Table 4.4 Linear Regression Analysis of Independent variables

Independent variables Coefficient

Salary 0.0768928

Incentive -0.0282575

Working Environment 0.1222373

Distributed Responsibilities & Time 0.3197933

Social Acceptance -0.120277

Safety & Security -0.025436

Feedback from Authority 0.2384278

Equipment Facility -0.60599

Staffs & Resources 0.3957916

47

We have worked with 30 nurse’s satisfactory independent variables such as salary, incentive,

working environment, distributed responsibilities & time, social acceptance, safety &

security, feedback from authority, equipment facility, staffs & resources. We have constructed

linear regression chart relating to its coefficient helps to describe a mathematical solution into

this set of independent variables. There are two outcomes among independent variables such

as positive constants and negative constants.

Positive constants are the set of independent variables which increases nurse’s job satisfaction

and on the other hand negative constants decreases satisfaction. For example: - If the salary

increases by one unit then job satisfaction will increases by 0.0768928 units. If the incentive

goes by one unit then job satisfaction will decreases by 0.0282575 units. As a whole we can

tell that positive independent factors such as salary, working environment, distributed

responsibilities & time, feedback from authority, staffs & resources are the most influencing

need among nurses job satisfaction. Medical Authority should work on that matter for

providing superior health care delivery in a way that will satisfy nurse’s job satisfaction.

Analysis of Salary among Nurses:

Average Salary of 30 Nurses = 17533.33333

Standard Deviation shows how much variation exists from the average.

• A low standard deviation indicates that the data points tend to be very close to the mean.

• A high standard deviation indicates that’s the data points are spread out over a large range of

values.

Standard Deviation among 30 Nurses = 2431.592827

Upper Limit = 17533.33333+2431.592827

= 19964.92616

Lower Limit = 17533.33333-2431.592827

= 15101.7405

48

Table 4.5 Standard deviation of salary of nurses

Serial

number

Name Age Salary (BDT)

1 Selina Begum 42 17000

2 Julekha Begum 43 18000

3 Shohida Naznin 39 17000

4 Mazia Aktar 42 18000

5 Shormitha Paul 35 15000

6 Jasmin Aktar 38 16000

7 Shanzida Aktar 40 17000

8 Yesmin Haque 45 19000

9 Sumaya Begum 38 16000

10 Tamanna Begum 45 20000

11 Farzana Khatun 40 18000

12 Shorifa Khatun 41 19000

13 Mira Ghosh 45 20000

14 Rina Khatun 45 21000

15 Latifa Begum 38 17000

16 Shahina Rahman 41 19000

17 Farida Parvin 35 14000

18 Rokhsana Parvin 37 15000

19 Ayesha Khatun 48 22000

20 Nasima Begum 38 16000

21 Romena Khatun 39 16000

22 Rahima Khatun 42 20000

23 Afraza Begum 41 19000

24 Sultana Sharmin 43 18000

25 Amrita Ray 40 18000

26 Bilkis Begum 36 15000

27 Anguri Begum 48 23000

28 Rahela Begum 37 16000

29 Monni Aktar 36 15000

30 Saniya Begum 28 12000

49

From this above observation we can easily observe salary deviation from a sample (n) of 30

nurses bearing large population (N). Average nurses salary exists between 15101.7405 BDT

to 19964.92616 BDT. Their yearly increment of salary is very poor. Even the senior nurse’s

salary does not exceed 23000. New coming nurse’s salary does not exceed 12000. It shows

poor salary range among the sample (n) of 30 nurses. Their salary does not fulfill their own

personal desired needs and so they are not satisfied. But they have to dedicatedly work for the

sake of patients during long work hour shift. If the authority make proper steps for increasing

salary then it should encouraging among nurses to develop their professional carrier on this

particular sector.

50

Chapter-5

Discussion on Results

From the very beginning of our thesis work as our topic was “The Determinants of Job

Satisfaction among Nurses of Government Hospitals a case study in Bangladesh”, firstly we

have conducted survey question paper for nurses. In order to analyze our survey question

paper we have visited two renowned public hospitals such as Dhaka Medical College Hospital

and Shaheed Suhrawardy Medical College Hospital.

We have surveyed 30 nurses in different units of these two hospitals. Initially we have done

pie chart for all individual question answer but that was not well enough for taking proper

decision. Then we have sorted out 9 independent factors which are strongly related to the job

satisfaction of nurses. Then we made a tabular method for each individual unit for nurses and

also set three different criteria (satisfied, dissatisfied, no comments) to evaluate a bar chart

calculation for nurses job satisfaction among independent factors. From the overall bar chart

calculation we have found five most critical points such as salary, distributed responsibilities

& time, safety & security, feedback from authority, staffs & resources. By observing bar chart

feedback from authority was the most critical problem and also second most critical problem

was staffs & resources among.

We made reciprocal relationship between the three domains of nursing practice environment,

nurse’s job satisfaction and quality of nursing care. Healthy interactions between nurses that

generate trust and gratitude were seen to positively impact the domains the opposite was

noticed in case of unhealthy interactions. Management practices in nursing administration

should invest for healthy human relations to achieve enhancements across the three domains.

As nurses interact with each other to deliver patient care, they also experience an

51

interrelationship between these three domains. Unhealthy interaction between nurses can

create mistrust and jeopardize progress in the three domains. So there is little doubt to the

merit of such investment.

On the time of surveying we have known approximate salary of these 30 nurses. From this we

have found average salary of 30 nurses is around 17500 and also standard deviation among 30

nurses is around 2400. So from analysis average nurses salary exists between 1500 BDT to

19900 BDT. Their yearly increment of salary is very poor. Even the senior nurse’s salary does

not exceed 23000. New coming nurse’s salary does not exceed 12000. It shows poor salary

range among the sample (n) of 30 nurses from large population (N). Their salary is very poor

because they have to give so much effort for the sake of patients. In the medical job, nurses

are the ones who have diversified tasks and are required to take up multiple responsibilities at

their workplace. Their salary does not motivate them to satisfy their desired needs. Salary

should be encouraging for nurses in spite their very hard work.

We have constructed linear regression chart relating to its coefficient helps to describe a

mathematical solution into this set of independent variables. There are two outcomes among

independent variables such as positive constants and negative constants. Positive constants

such as salary, working environment, distributed responsibilities & time, feedback from

authority, staffs & resources which are most important factors for nurse’s job satisfaction.

From this analysis these five factors are most influencing for nurse’s job satisfaction but also

others factors are also can be improvable. Medical Authority should work on that matter for

providing superior health care delivery in a way that will satisfy nurse’s job satisfaction.

Furthermore

We have developed Herzberg’s two factor theory. Frederick Herzberg, who theorized that job

satisfaction and job dissatisfaction act independently of each other. Two-factor theory

distinguishes between motivators and hygiene factors. Intrinsic (motivating) factors focusing

on job satisfaction such as salary, distributed responsibilities & time, staffs & resources,

safety & security, Incentive. Extrinsic (hygiene) factors focusing on no job satisfaction such

as working environment, feedback from authority, social acceptance, feedback from authority.

For example- Salary is the most motivating factors for nurse’s job satisfaction and on the

other hand working environment is the most hygiene factor for nurse’s job dissatisfaction.

52

Chapter-6

Conclusions and Recommendations

Determinants of job satisfaction of nurses are the factors upon which the job

satisfaction level of nurses depends. And main purpose of our analysis was to determine the

main factors of job satisfaction level of nurses. For the analysis we needed information and

we conducted a survey to acquire the required data among 30 nurses of two government

hospitals of Bangladesh. Then by data analysis, conceptual frame work, Herzberg’s two factor

theory, and regression analysis and so on we found out the main factors and which are the

most effective ones on job satisfaction level of nurses.

By analyzing the gathered data we found the main factors which have a great impact

upon the job satisfaction level of nurses. As in Herzberg’s two factor theory we found the

motivating and hygiene factors which can be used in order to increase the level of job

satisfaction. Again in regression analysis we found the most effective factors with the help of

coefficients. The factors with positive coefficients can be modified to obtain enormous result

on the job satisfaction level of nurses. Also we have calculated the standard deviation of

salaries of the 30 nurses which is very poor and demoralizing. Here also problem in working

environment and distributed responsibilities & time. So increasing the salary recruit more

stuffs in this occupation can do an enormous effect upon the job satisfaction level of nurses of

Bangladesh.

53

Chapter-7

References

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characteristics. Journal of Advanced Nursing 32 (3), 536–543.

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organizational features of acute hospital wards. International Journal of Nursing

Studies 32 (6), 612–627

AL-Hussami M (2008). A Study of nurses' job satisfaction and the relationship to

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F. Herzberg (1966) Work and the Nature of Man. Staple Press. London.

A.H. Maslow (1954) Motivation and Personality. New York: Harper & Row.

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AL-Hussami M (2008). A Study of nurses' job satisfaction: The relationship to organizational

commitment, perceived organizational support, transactional leadership,

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177- 183.

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F. Herzberg (1966) Work and the Nature of Man. Staple Press. London.

Greenberg, J., & Baron, R. A. (1993). Behavior in organizations (4th ed.). Needham

Heights, MA: Allyn and Bacon.

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of Applied Psychology, pp95-105

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Appendix

Questionnaire for the Determinants of Job satisfaction of

Public Hospital Nurses

Conducted By Department of Industrial & Production

Engineering Ahsanullah University of Science & Technology 141 & 142, Love road, Dhaka 1208

Name of the Organization / Hospital

Location

Sociodemographic Data

Name Age

Sex Male Female

Marital status Married Single

Work experience less than 2 years More than 2 years

Previous work experience Yes No

Educational status Bachelor Diploma

Nationality Bangladeshi Others

Unit of work Medical Maternity Burn OPD

Surgical Casualty ICU Others

Professional Training(If any)

Nurse patient ratio in your ward/unit

Member of any association

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Job Satisfaction Subscale

Cases Agree Disagree Neither Agree

nor Disagree I feel encouraged to come up with new and better ways of

doing things.

My work gives me a feeling of personal accomplishment

I have the staffs and resources to do my job well.

When a patient is dissatisfied, I can usually correct the problem to their satisfaction. I am satisfied with the work environment

I am rewarded for the quality of my service

I respond quickly and courteously to fulfill patient’s needs I have observed or experienced any types of harassmen

Equipments & other Job Resources

Are all these following equipments available in your unit/ward?

Staffs & Equipments Yes No

Emergency antiseptic facility

Gloves, masks, uniforms & other nursing apparel

Blood pressure monitors

Eye & wound wash

Pulse oximeters

Syringes & needles

Bandages, tapes & tourniquets

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Job Oriented Information

1= Unsatisfied

2= Somehow unsatisfied

Evaluate the following cases on a scale of 1-5 3= Somewhat satisfied

4= Satisfied

5= Very satisfied

Cases 1 2 3 4 5

How satisfied are you with your preceptor?

How satisfied are you with your position in the unit/ward?

How satisfied are you with the nursing staff as a resource?

How satisfied are you with the work environment?

How satisfied are you with the ability to advance within your facility?

How satisfied are you with the ability to advance within the nursing

profession?

How satisfied are you with the hours that you work?

How satisfied are you with your salary?

How satisfied are you with your shifting?

How are you treated in the society for your job?

Safety Related Information Have you experienced any of the following common nursing injuries?

Injuries Yes No

Overexposure to lengthy and demanding shifts

Standing for long periods of time with increased fatigue

Taking on the work of two people due to inadequate staffing

Inadequate enforcement and monitoring by management of patient

weight handling procedures.

Do you aware & exercise the safety measures in your unit?

Do the other nurses aware about safety precaution?

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What do you consider the biggest problem on the job?

Payment/ salary Feedback from authority Equipment facility Incentive Staffs and resources working environment Safety & security Social acceptance Distributed responsibilities and time Others

On a scale of 1 – 10 (one = worst and 10 = very satisfied) how would you rate your satisfaction with the nursing profession?

What would you do to make the nursing profession more appealing?

Thank you

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