CHAPTER -4 ANALYSIS AND FINDINGS -...

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CHAPTER -4

ANALYSIS AND FINDINGS

This chapter brings out data analysis and interpretations. The data collected from

different sources have been organized in order to bring out effective findings and

conclusions. The main sources of data collection are the nursing staff, heads of

nursing and hospital, hospital records, and observed field data. This chapter is

organized into three major main parts namely Part – 1. Demographic Profile and

Job Characteristics, Part – 2 Working conditions and facilities provided to the

nursing staff, Part – 3 Over view of Quality indicators.

Part I of this chapter is “Demographic Profile and job characteristics”. This

provides the findings about the nursing staff background and their work related

characteristics. The information presented in this segment is based on the structured

interview scheduled administered with 317 nursing staff, data collected from

administrative and nursing heads of the sample hospitals (key informant interview)

by guided interview schedule and data obtained from the hospital records

(secondary data).

Part II of this chapter is “Working conditions and facilities provided to the nursing

staff”. This presents the findings of the variables like physical facilities,

organisational policies, professional development, work teams, respectful

relationship, supervision and management, and service quality and patient safety.

The information provided in this segment is based on the structured interview

scheduled administered with 317 nursing staff, data collected from head of the

hospitals and nursing heads of the sample hospitals by unstructured in depth

interview.

Part III of this chapter is “Quality of work life indicators”, this part covers variables

like work life balance, absenteeism, work stress, communication, job satisfaction,

organisational culture and climate, and nursing staff’ perception on their work

performance. There are seven variables covered in this segment.

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Chapter – 5 covers the effect of job characteristics and working conditions and

facilities on quality of work life of the nursing staff”. In this chapter the findings of

key variables of Part-1 and Part-2 are cross examined with Part-3 Quality of Work

Life indicators variables to understand “the effect of job characteristics and working

conditions and facilities on the quality of work life of nursing staff”. The effect on

quality of work life of nursing staff due to demographic profile of nurses, job

characteristics, working conditions and facilities is analysed by applying statistical

tools like chi-square tests, logistic regression and correlation. Also the data are

analysed and presented in the form of cross tables.

The final chapter of analysis is “Chapter-6 Key Informant Interviews on nursing

work environment”. In this segment the views shared by the heads of the nursing

department like matron, assistant matron and hospital head medical superintendent

or chief medical officer examined. A guided interview schedule was used to collect

the information from theses respondents. These respondents also called key

informants, as they have shared information with regard to nursing staff problems,

challenges, work related issues, factors affecting their routine work, working

conditions and facilities provided to the nursing staff etc.

Overall in this chapter some of the statistical tools used for analyzing data were

percentages, mean, standard deviation, chi-square test etc. Also two way tables

were used to describe the variables of the study. In addition to this, a multivariate

tool of Logistic regression, has been used to bring out appropriate findings and meet

the requirement of study objectives from the available data. In brief these statistical

tools have played vital role in exploring the important aspects of the phenomenon

and analyzing all important variables of this research study.

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PART-1 DEMOGRAPHIC PROFILE AND JOB CHARACTERISTICS

Section – ‘A’ Demographic Profile of the respondents

This section provides useful information to understand the demographic profile and

job characteristics of the respondents. The respondents are 317 nursing staff who

have completed three years of experience in Municipal Peripheral hospitals in

Mumbai. The findings below relate to significant aspects of the respondents’ social,

economic and job related characteristics.

Age, Education and Experience

Age: The nursing staff age, education and their experience are presented in table

1.1. The mean age of respondents is 42. The standard deviation of age (8) indicates

that large numbers of respondents have reached middle age. The middle age group

has its own behaviour and associated issues like health, adjustment to working

conditions and facilities, promotions and other opportunities. As they grow older

the nurses are expected to have improved knowledge and skills, maturity, and

commitment to the work. It is also expected that patients would feel confident when

the staff which is present is older in age. Also the senior staff would be good

sources for providing coaching and training to the young staff at the ward level.

They command respect from coworkers and other groups. On the other hand they

might resist changes like computerisation, or modernization including use of latest

technology because they need to acquire new skills which would be difficult for

them to acquire at a older age.

Experience: The mean total experience of respondents is 19 years. The total years

of experience of the nursing staff include their current experience in the present

hospital and experience in similar BMC peripheral hospitals. The mean years of

experience in the present hospital is 15 years. It is clear that the work age of

beginner nurses is 23 years (mean age is 42 minus mean total experience 19 equal

to 23 years) and before they took up the current positions they had worked on an

average of 4 years (total mean experience 19 years minus mean present hospital

experience 15 years) in other hospitals including BMC hospitals. The nursing staff

have gained long years of experience in the same hospitals. Even though the

nursing staff have various opportunities and scope to work in other places including

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abroad, they have not moved away. Also it indicates that there is hardly any nursing

staff turnover in these hospitals. Since the majority of the staff have continued to

serve in the same hospitals it helps the staff to understand the value system of the

hospitals and patients’ behaviour, and this facilitates better coordination between

the patients and the staff. The nursing staff are able to easily understand the patient

background, cultural and social requirement of the patients at the early stage of

patients’ stay. As a result, the patients get appropriate support right from the time of

their admission into the hospital.

Education: Among the respondents, a majority of the nursing staff, nearly 71 per

cent, are qualified with a nursing diploma with Higher Secondary Course (HSC)

which is the currently considered as minimum educational eligibility for a staff

nurse position. However, 28 per cent of the nursing staff have a diploma in nursing

with Secondary School Leaving certificate (SSLC) or Standard X. These nurses are

relatively older nurses and had joined the hospitals before the introduction of HSC

as a requirement. There is only one per cent of staff who have a degree with nursing

diploma or Degree in nursing courses as seen in the sample hospitals. It is seen that

there is no necessity for the nursing staff to carry on higher studies as there is no

perceived benefit associated with higher qualification. Also there is a reason to

believe that majority of the staff have middle age health factors and family

responsibilities that undermine any effort of upgrading their qualifications. It is

reported that the Indian Nursing Council is trying to bring degree in nursing as the

basic qualifications for nursing services where the present qualifications of Staff

nurses (diploma in nursing) will be replaced by the degree holders as and when

these nursing staff retire. One of the matrons in the study hospitals pointed out that

“by 2010 new recruitment will start with only degree in nursing candidates”. In the

near future the diploma in general nursing and midwifery holders will be no longer

potential candidates in the public hospitals. Also the nursing educational institutions

are likely to stop training diploma nurses in the coming years.

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TABLE -1.1 Respondents Age, Education, and Experiences

Age of the respondents Present designation Total Staff Nurse Sister

incharges Below 30 yrs 27 (10.2) 1 (1.9) 28 (8.8)31-35 yrs 48 (18.2) 2 (3.8) 50 (15.8) 36-40 yrs 58 (22.0) 5 (9.4) 63 (19.9) 41-45 yrs 63 (23.9) 7 (13.2) 70 (22.1) 46-50 yrs 42 (15.9) 3 (5.7) 45 (14.2) 51 & above 26 (9.8) 35 (66.0) 61 (19.2)Education X2 = 90.73 P=.000 SSLC with Nursing Diploma 55 (20.8) 34 (64.2) 89 (28.1)H Sc with Nursing Diploma 205 (77.7) 19 (35.8) 224 (70.7)Others 4 (1.5) 0 (0.0) 4 (1.3)Total years of experience X2 = 41.21 P=.000 Up to 5 yrs 30 (11.4) 0 (0.0) 30 (9.5)6-10 yrs 36 (13.6) 3 (5.7) 39 (12.3)11-15 yrs 89 (33.7) 7 (13.2) 96 (30.3)16-20 yrs 58 (22.0) 5 (9.4) 63 (19.9)21-25 yrs 42 (15.9) 12 (22.6) 54 (17.0)26- & above yrs 9 (3.4) 26 (49.1) 35 (11.0)Experience in present hospital X2 = 102.39 P=.000 Up to 5 yrs 41 (15.5) 15 (28.3) 56 (17.7)6-10 yrs 30 (11.4) 5 (9.4) 35 (11.0)11-15 yrs 70 (26.5) 2 (3.8) 72 (22.7)16-20 yrs 80 (30.3) 4 (7.5) 84 (26.5)21-25 yrs 30 (11.4) 7 (13.2) 37 (11.7)26 & above 13 (4.9) 20 (37.7) 33 (10.4)Total 264 (100) 53 (100) 317 (100) X2 = 68.67 P=.000

(Figures in brackets indicate the percentage of nursing staff) N=317

Family Size and Background

The size of the family includes adults, children and dependents. The details are

presented in Table -1.2 Adults, children and dependents. The mean number of adult

in the nursing staff family is 3 and the standard deviation is 1. Nursing staff family

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size is one of important factors to decide on a professional career because being a

female worker they have greater responsibilities to take care of the family members

particularly the young children and elderly persons in the family. It is expected that

if the family members are adults and are able to manage themselves, the nursing

staff have slightly less home responsibilities. Also the adult members are able to

understand the nature of nursing profession and try to extend support and

cooperation to the nursing staff. Another advantage is that there is a possibility to

get financial support from the adult members subject to their earning capacity.

However, the nursing staff do have certain responsibilities of supporting the adult

members in terms of providing financial support if they are pursuing higher studies,

unemployed or any other reason that adds to the tension of the nursing staff.

The mean number of children in the nursing staff family is 1.7 and the standard

deviation is 0.6. Nearly 38 per cent have only one child and 57 per cent have two

children in the present scenario. A majority of the nursing staff have followed the

governmental norm of “we two, ours two”. This is because of the nursing staff’s

high awareness on family planning, living in an urban environment, more oriented

towards having small and compact families. Another reason for having only one or

two children is most of the nuclear family set up wherein the family consists of only

the husband and wife and there are no other members, elders or relatives or trust

worthy persons, to take care of their off spring. It is to be noted that some the

nursing staff mentioned that “young and school going children take much of our

time and give us more challenges by demanding more attention, and support.”

Another issue is that the nursing staff have to pay more attention to their work

because of the above reasons and the nursing have consciously avoided having a

larger family.

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TABLE -1.2

Nursing Staff Family Members: Adults, Children and Dependents

Number of Adults Present designation

Total Staff Nurse Sister incharges Up to 2 102 (38.6) 13 (24.5) 115 (36.3)

3-4 134 (50.8) 26 (49.1) (50.5)160

5-6 25 (9.5) 14 (26.4) (12.3)39

7+ 3 (1.1) 0 (0.0) (0.9)3

Number of children 1 70 (38.3) 12 (38.7) 82 (38.3)

2 106 (57.9) 15 (48.4) 121 (56.5)

3+ 7 (3.8) 4 (12.9) 11 (5.2)

Number of dependents X2 = 13.35 P=.004 1 49 (20.8) 15 (32.6) 64 (22.7)

2 122 (51.7) 23 (50.0) 145 (51.4)

3 46 (19.5) 6 (13.0) 52 (18.4)

4 14 (5.9) 1 (2.2) 15 (5.3)

5 3 (1.3) 0 (0.0) 3 (1.1)

6 2 (0.8) 1 (2.2) 3 (1.1)

Total 236 (100) 46 (100) 282(100) X2 = 7.28 P=.063

(Figures in brackets indicate the number of nursing staff) N=317

The mean number of dependents in the nursing staff family is 2. Nearly 46 per cent

of the nursing staff have two dependents, 20 per cent have only one dependent.

These dependents are mostly their own children and in-laws who are staying with

the nursing staff. Other than caring for elders and the children who require more

attention and well being the nursing staff also provide economic and monetary

support to these dependents.

Economic conditions of nursing staff

The smooth functioning of a family unit is connected with various requirements

including financial support. In the nursing staff family there are few members

earning and providing support. The details of economic support and other aspects

are presented in table Table1.3

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Majority of nursing staff 74 per cent have two earning members in the family which

include self and their spouse. Nearly 13 per cent of the staff have a single earning

member that is mostly self income. However, the mean earning member in the

nursing staff family is 2 and the standard deviation is 0.7. In normal circumstances,

it is expected every male has to work in Indian traditional families. If it is

considered the male has to work in addition to that the female member also working

so every nursing staff family is supposed to have two earners in a family which

brings in an additional economic support for the family.

Nearly 59 per cent of the nursing staff receive a salary between Rs.14000 to

Rs.17000 which is a reasonable salary as per the Indian economy, but to earn this

salary the staff have to put in at least an average of 19 years of service in the

hospitals. The system is such that more the years of experience of the nursing staff,

the higher the salary due to yearly increments. The nursing staff average self

income is Rs.15,301 per month per person and the standard deviation is Rs.2049.

However, the mean income is not the actual take home salary. There are some

standard deductions applicable like professional tax, contribution to provident fund,

loan recovery, LIC, Income tax etc.

Nearly 39 per cent of staff have a family income of Rs.20001 to Rs.25000. The

mean income of the family is Rs.22,831. The difference between the self-income

and family income is Rs.7530 per month. It means, on an average, extra income

other than self generated is Rs.7530 per month. In other words, the spouses’ earning

is really low when compared to that of the nursing staff. In such situations if the

nursing staff do not work, the family is likely to face economical crises. Even

though there is an average of two persons who earn in the nursing staff family,

many nursing families depend on the nursing staff income as main source of

income. Therefore, even if a nurse wishes to leave her job she cannot leave the job.

The total family members are 1742 which includes 1024 adults and 359 children.

The per capita income of the family members is Rs.4155 person per month which

include the both the self and spouse. If the children are excluded from the

calculation of per capita income it works out Rs.7068. While comparing the

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nursing staff family members’ per capita income Rs.4155 with national per capita

income Rs.3333 per month per person (World Bank Report, 2007) the nursing staff

family members have a higher per capita income per month.

TABLE1.3

Economic Support and Income Status of the Staff

Occupation of spouse Present designation

Total Staff Nurse Sister incharges Unsecured job 179 (73.7) (34.7)17 196 (67.1)

Secured job 51 (21.0) (30.6)15 66 (22.6)

Retired 13 (5.3) (34.7)17 30 (10.3)

Number of earning members in the family X2 = 55.94 P=.000 1 32 (12.1) 8 (15.1) 40 (12.6)

2 205 (77.7) 29 (54.7) 234 (73.8)

3 15 (5.7) 10 (18.9) 25 (7.9)

4 8 (3.0) 4 (7.5) 2 (3.81)

5 3 (1.1) 2 (3.8) 5 (1.6)

6 1 (0.4) 0 (0.0) 1 (0.3)

Monthly self income X2 = 17.71 P=.003 Up to Rs. 8000/- 3 (1.1) 0 (.0) 3 (.9)

Rs.8001-11000/- 7 (2.7) 0 (.0) 7 (2.2)

11001-14000 82 (31.1) 4 (7.5) 86 (27.1)

14001-17000 158 (59.8) 31 (58.5) 189 (59.6)

17001 & above 14 (5.3) 18 (34.0) 32 (10.1)

Monthly family income X2 = 46.930 P=.000 Rs.10000 -15,000 17 (6.4) 1 (1.9) 18 (5.7)

Rs.15001 to Rs.20000 68 (25.8) 11 (20.8) 79 (24.9)

Rs.20001to Rs.25000 106 (40.2) 17 (32.1) 123 (38.8)

Rs.25001to Rs.30000 51 (19.3) 21 (39.6) 72 (22.7)

Rs.30001 to Rs.35000 9 (3.4) 2 (3.8) 11 (3.5)

Rs.35001 and above 13 (4.9) 1 (1.9) 14 (4.4)

Total 264 (100) 53 (100) 317 (100) X2 = 11.74 P=.038

(Figures in brackets indicate the number of nursing staff) N=317

Nearly 51.7 per cent of the spouses are working in private companies and 14.5 per

cent work in Government organisations. Further, the jobs are classified under

secured and not so secured to have clear view about the nature of job and how they

meaningfully support the nursing staff family. It is found that nearly 59.3 per cent

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of the spouses of the nursing staff are working in private companies and the casual

work sector that are both unsecured. However 20.8 per cent of the spouses of

nursing staff are working in secured positions like government job, corporations,

banks etc. Secured job and unsecured job makes lot of difference in the nursing

staff mindset. It has been observed that some nursing staff are very happy to

mention the occupational status of their husband only if he possesses a secured or

white-collar job or runs his own business. On the other hand, if the staff’s spouse

has a job in the private sector or in employed in a temporary occupation, the staff

mentions their spouse’s occupation with some hesitation. Some of the staff stated

that their husbands are not willing to take up a job. This increases their mental

tension and there is no financial support from their spouse.

Nursing staff’s Marital Status, Religion and State of Origin

Nursing staff’s marital status, their religion and the state of origin is presented in

table number 1.4. Among the respondents nearly 92 per cent are married and only 6

per cent are unmarried. Married nursing staff have many problems which include

time pressure, developing professionalism, raising and managing the children and

other work related issues. Some of the nursing staff mentioned that their children

are latch-key kids. It is because there are no facilities in the work place or there is

nobody is to take care of the children at home and childcare facilities are either

easily available or expensive. Many senior nursing staff have reported that because

of the work shifts they have missed out on enjoying quality time with their children.

The majority of the nursing staff i.e. 84.5 per cent belongs to Hindu religion and

nearly 13 per cent of the staff are Christian. The nursing profession and religion are

traditionally closely associated. Nursing services were introduced in India by

missionaries and later it was recognised as a profession in the country. Since the

beginning Christians used to take up nursing as a profession and make it their career

choice. It is perceived that there is no practice of taking nursing as a career choice

in Hindu communities. But in the study of hospitals it has been found that majority

are belonging to Hindu religion. It shows that the religion is no long longer a factor

when choosing the nursing profession and secondly that Hindu families have

accepted that their children have a right to choose nursing as profession. Another

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reason for accepting nursing a career choice is that it gives enough employment

opportunities for women in private, government and corporations which in turn

provides a constant source of income to the family. Moreover, the women

irrespective of any religion who takes up nursing profession get satisfaction while

serving the community.

The majority of the staff (91 per cent) are Maharashtrians and only 6 per cent hail

from Kerala. It shows that the recruitment is restricted to only within the state of

Maharashtra. The Maharashtrians being localities can understand the local

languages of the state, the difficulties of the patients and are able to communicate

with the patients without any language barrier. However, there are certain issues

associated with the present system – in case the hospitals need more number of

nursing candidates to compensate the existing shortage or additional requirements if

any it would be difficult to identify workforce within the state because there may be

inadequate number of nursing candidates who are trained within the state and there

is scope for such candidate to migrate aboard.

TABLE – 1.4 Nursing Staff Marital Status, Religion and State of origin

Variables

Present designation

Total Staff Nurse Sister incharges Current marital status Unmarried 17 (6.4) 2 (3.8) 19 (6.0)

Married 243 (92.0) 49 (92.5) 292 (92.1)

Widowed 3 (1.1) 2 (3.8) 5 (1.6)

Divorced 1 (0.4) 0 (0.0) 1 (0.3)

Religion Hindu 222 (84.1) 46 (86.8) 268 (84.5)

Muslim 4 (1.5) 1 (1.9) 5 (1.6)

Christian 36 (13.6) 5 (9.4) 41 (12.9)

Others 2 (0.8) 1 (1.9) 3 (0.9)

State of origin Maharashtra 242 (91.7) 47 (88.7) 289 (91.2)

Kerala 13 (4.9) 5 (9.4) 18 (5.7)

Karnataka 3 (1.1) 0 (0.0) 3 (0.9)

Other states 6 (2.3) 1 (1.9) 7 (2.2)

Total 264 (100) 53 (100) (100)317(Figures in brackets indicate the number of nursing staff) N=317

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Travelling between the workplace and residence and related matters

The details of place of stay, travel distance, mode of transport, duration of travel

and amount spent on travel are discussed in table 1.5. Most of the respondents stay

in different locations and are spread all over Mumbai and its suburban areas. The

respondents stay in nearly 60 different locations. Nearly 13.6 per cent of the

respondents stay in Borivili. This is the highest concentration of staff in a single

location. Many respondents stay far away from their work place. In Mumbai most

of the areas are well connected with the transport facilities. Since the nursing staff

follow the shift system and the duty timings are different from non-peak hours it

would be possible for them to travel easily. The nursing staff are not provided with

quarters. Hardly any staff have got accommodation within the hospitals. Even if the

hospitals provide quarters some of the staff members hesitate to occupy such

facilities because they have to work as substitutes or relievers and have to be

available 24 hours on call. In fact, a few nursing staff complained that “they have

been used very frequently as a substitute for absentees”.

A majority of the nurses, nearly 55 per cent, stay close to their work place, within 5

kilometers, and another 11 per cent of the staff stay between 16 – 20 kilometers.

The mean distance between workplace and the place of residence is 11 kilometers

and the standard deviation is 18 kilometers. The nursing staff have an option of

choosing from a variety of modes of transport. Nearly 43.8 per cent of the nursing

staff travel by train while 29.3 per cent travel by bus. Usually, the nursing staff use

multiple modes of transport to reach the hospital. The nursing staff use train and

auto or train and bus etc. because the work place is far away from the railway

station or sometimes the residence is far away from the railway station. Using

multiple modes of transport increases travel fatigue and this results in an attitudinal

change in the work place as well in the family set up. The nursing staff that use only

trains as their mode of transport feel that is faster and cost effective but are

uncomfortable to the overcrowding that Mumbai trains are famous for.

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TABLE-1.5

Travel to Work Place and Related Issues

Variables

Present designation

Total Staff Nurse Sister incharges

Mode of transport Walk (8.7)23 5 (9.4) 28 (8.8)

Auto (2.3)6 1 (1.9) 7 (2.2)

Bus (29.5)78 11 (20.8) 89 (28.1)

Train (44.7)118 28 (52.8) 146 (46.1)

Train and Auto (1.1)3 0 (0.0) 3 (0.9)

Bus and Train (11.0)29 8 (15.1) 37 (11.7)

Own vehicle (2.7)7 0 (0.0) 7 (2.2)

Distance between the work place and residence Upto 5 kms 150 (56.8) 23 (43.4) 173 (54.6)

6-10 kms 25 (9.5) 5 (9.4) 30 (9.5)

11-15 kms 19 (7.2) 4 (7.5) 23 (7.3)

16-20 kms 27 (10.2) 8 (15.1) 35 (11.0)

21-25 kms 13 (4.9) 1 (1.9) 14 (4.4)

26-30 kms 4 (1.5) 1 (1.9) 5 (1.6)

31-35 kms 5 (1.9) 1 (1.9) 6 (1.9)

35+ kms 21 (8.0) 10 (18.9) 31 (9.8)

4-5 hours 17 (6.4) 4 (7.5) 21 (6.6)

5 & above hours 26 (9.8) 8 (15.1) 34 (10.7)

Amount spent on travel No expenses 25 (9.5) 3 (5.7) 28 (8.8)

Up to Rs.200 32 (12.1) 5 (9.4) 37 (11.7)

Rs.201-400 96 (36.4) 15 (28.3) 111 (35.0)

Rs.401-600 64 (24.2) 16 (30.2) 80 (25.2)

Rs.601 & above 47 (17.8) 14 (26.4) 61 (19.2)

Total duration of away from residence 8-9 hours 49 (18.6) 4 (7.5) 53 (16.7)

9-10 hours 172 (65.2) 37 (69.8) 209 (65.9)

11-12 hours 37 (14.0) 10 (18.9) 47 (14.8)

13 & above hours 6 (2.3) 2 (3.8) 8 (2.5)

Total 264 (100) 53 (100) 317 (100)(Figures in brackets indicate the number of nursing staff) N=317

The mean time spent on travel is 1.4 hours (table1.6). Nearly 32 per cent of staff

stay close to the hospital hence they spend just about 15 minutes on travel to and

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from the workplace. Nearly 28 per cent of the staff spend one hour on travel and

another 21 per cent spend two hours on travel. Many nursing staff have their own

houses in suburban areas. They have got these houses in suburban areas because the

cost of flats is relatively cheaper there, but these places are considerably far from

their work place. It is to be noted that a majority of study hospitals located in

suburban areas and all the hospitals have been well connected with transport

systems and this saves a lot travelling time. However, the nursing staff have to face

a crowd while travelling even though they may travel in non-peak hours. There are

many occasions the staff face traffic problems especially when they travel by bus.

This delays them when reaching the hospital or home. The nursing staff spend a

reasonable amount of their income on travel since majority of the respondents travel

by train which is relatively cheaper and faster transport service.. The mean travel

expenses is Rs.455 per month and the standard deviation is Rs.305. Nearly 30 per

cent of the staff spend Rs.201 to Rs.400 as monthly travel expenses. Only 11 per

cent of the staff spend less than Rs.200 as monthly travel expenses.

The nursing staff spend more than one third of the day away from their family. The

usually are at work or are travelling and these two constitute the total time spent

away from the residence. The nursing staff’s mean time away from the residence is

9 hours and 40 minutes and standard deviation is 1 hour 30 minutes. Nearly 32 per

cent of the nursing staff have indicated that they spend up to 8 hours in the hospital

and another 31 per cent of the staff spend 8-9 hours in the hospital. In fact, nearly

63 per cent of the above two categories 32 +31 of the nursing staff reported that

they spend less than 9 hours which is comparatively lower than the mean time. It is

reported that staying longer hours away from the residence affects the personal life

particularly managing the children’s education, emotional support and well being. It

is to be noted that when the mother is away for longer hours, children are likely to

get upset and learn abnormal behaviour. There is significant association between

the travel time and distance traveled by the nursing staff (r = 0.513). The table 1.6

presents the summary of statistics used in chapter-4 Section -A.

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Table 1.6 Summary Table

Variables Mean Median Mode S D Mini mum

Maxi mum

Age 42.0 43 45 8.3 24 58

Total years of work 18.9 18 15 7.4 3.5 36

Years in Present Hospital 14.8 15 15 7.8 0 33

No. of Adults 3.2 3 2 1.4 1 13

Children below 14years 1.7 2 2 0.6 1 4

No. of dependent members 2.1 2 2 0.9 1 6

No. of earning members in the family 2.1 2 2 0.7 1 6

Monthly Self income 15327 16000 17000 2018 7000 19000

Monthly Family income 22831

Distance between workplace and residence 11.3 3 0 18.2 0 200

Total duration away from the residence in a day 9.6 9 9 1.3 7.3 14

Travel hours 1.6 1 1 1.2 0.3 6

Amount spend on travel 456.3 400 400 304.5 0 1500

Section B: Job Characteristics

1. Nursing organisation in the sample hospitals

Nursing department in Peripheral hospitals follows a simple organisational

structure. The structure consists of only five categories and the details are presented

in chart-1. The highest position in the hierarchy is Matron. She is the overall In-

charge of all the functions of the nursing department as well the nursing care system

in the hospital. The second in command in the hierarchy is Assistant Matron. She

provides administrative support in terms of supervising, organisation of functions,

interacting with all ward staff, taking the charge of all the nursing functions in the

absence of Matron. The third level is sister In-charge. She reports to assistant

matron or matron. She is provided with a set of responsibilities which will be

carried out on day-to-day basis. The sister in charge is a ward level staff and

provides support and facilitation to the staff nurses. The next category is staff nurse

position. Staff nurse carries out the nursing duties at the ward level and she is

responsible for the implementation pf the entire nursing programme. The last rung

of the hierarchy ladder is the ANM staff. The ANM staff assist in wards,

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particularly labour wards and maternity wards, in some hospitals. Once the ANM

staff get retired they are replaced by staff nurse.

Chart-1 Nursing organisational chart in BMC Peripheral Hospital

The matron and the assistant matron were interviewed separately through in-depth

interviews to bring out insights of study variables. The sister in-charge and staff

nurses were interviewed through structured questionnaires. The number of

respondents (sisters in-charge and staff nurses) participated in the study is presented

in chart-2. The information shared by matron and assistant matron along with head

of the hospitals is presented separately.

Chart-2 Percentage of staff participated in the study

Representation of staff for the study

17%

83% Sister in charge

Staff Nurse

Among the respondents nearly 83 per cent are staff nurses and 17 per cent are sister

incharges. The sister incharges are senior staff work in the ward along the

supervisory responsibilities. While comparing the staff nurse and sister incharges,

the staff nurses are higher in number as they are the field staff. Accordingly, the

Matron

Assistant Matron

Sister in charge

Staff Nurse

Auxiliary Nursing Midwife (ANM)

93

adequate and appropriate representation of these categories participated in the

study.

The nursing staff from various departments which include Outpatient Services,

Casualty, Operation Theatre, Burns Ward, Intensive care Unit (ICU), Medical

Intensive Care Unit (MICU), Pediatric Intensive Care Unit (PICU), Premature

Ward, Pediatric Ward, Trauma Intensive Care Unit (TICU), Male Surgical ward,

Male Medical ward, Male Ortho ward, Eyes Ear Throat ward (ENT), Female

Surgical Ward, Female Medical Ward, Female Ortho ward, Labour ward, Obstrics

and Gynecology ward (OBG), etc. participated in the study. For the purpose of

analysis all these wards are classified into five major categories. They are General

wards, Critical care units, Operation Theatre (OT), Emergency Services and OPD

services. The departments representation are presented in chart-3.

Chart-3 Present departments of the participants of the study

Nursing staff present departments

7%

55%7%

17%

14% Out Patient ServicesGeneral Ward ServicesEmergency ServicesOperation Theatre ServicesCritical Care Services

It is found that there is an appropriate representation from each department for the

study.

Nearly 55 per cent from general wards, 17 per cent from operation theatre, 14 per

cent from critical care units, 7 per cent from emergency services and 7 per cent

from OPD services nurse have participated in the study. In every hospital usually 5

to 10 per cent of the beds are provided for critical care services, and nearly 80 per

cent of the beds are general wards. The staff distribution is done in accordance with

the nature of care provided by the hospital.

94

2. Nursing work activities

The nursing staff are trained in three and half years in professional training

institutions. During this period they are provided with appropriate training in all the

areas of clinical and some aspects of non-clinical services so that they can easily

handle the patient care. When they join hospitals they are provided with variety of

opportunities in various work settings like different wards including general wards,

critical care wards, operation theatre and outpatient services. Even though the

nursing staff are capable of doing multiple tasks but they cannot do all the work at a

time. So it is important to prioritise work logically. Sometimes they continue to

perform a variety of complex functions and across various chains of activities so it

is very important to specify what work they have to do and when they are supposed

to do them. This specification can be called job description. The nursing staff’

duties and responsibilities are clearly specified in the job description. This ensures

that the staff can work in a focused way and that their time is utilised effectively to

achieve better patient care. The nursing staff job description is enclosed in appendix

-4.

Keeping this in view, the nursing staff are asked to spell out whether they are doing

their work as per their job descriptions or not. Nearly 19 per cent of nursing staff

reported that they do work other than the nursing work. The details are presented in

Table 1.7. It is observed that many nursing staff do non-nursing work and they

consider these tasks are part of the nursing care such as clerical work, inventory

management, handling of patient visitors, management of class IV staff etc.

Table 1.7 Nursing staff working as per your designation/job description

Are you doing work as per your designation/job description?

Present designation

Total Staff Nurse Sister incharges No 49 (18.6) 11 (20.8) 60 (18.9)Yes 215 (81.4) 42 (79.2) 257 (81.1)Total 264 (100.0) 53 (100.0) 317 (100.0)


This is because of lack of clarity of proper guidelines about the work they suppose

to carry out. In the absence of specific guidance or written guidelines the staff

managing their work based on the basic training received from nursing school

during their studentship. As a result these nurses continue to provide service with

95

their age old practices and there is no possibility of ushering in modern methods of

nursing practice. Details of non-nursing activities performed are presented in

Table1.8

Table 1.8

List of selected non-nursing activities performed by the nursing staff

Non-nursing activities performed by the nursing staff

Present designation Total

Staff Nurse Sister incharges Blood transfusion, inserting I V to the patients

19 (38.8) 5 (45.4) 24 (40.0)

Controlling the visitors, shifting patients one place to another

2 (4.1) 0 (0.0) 2 (3.3)

Election duty, and other government work 3 (6.1) 1 (9.1) 4 (6.7)

Giving kidney tray, pulling the Oxygen cylinder

11 (22.4) 2 (18.2) 13 (21.7)

Indenting of material, and maintenance of inventory in the ward

6 (12.2) 2 (18.2) 8 (13.3)

More clerical work includes reports, registers and formats

6 (12.2) 0 (0.0) 6 (10.0)

Taking lecture on cleanliness, and hand washing procedures

2 (4.1) 1 (9.1) 3 (5.0)

Total 49 (100.0) 11 (100.0) 60 (100)(Figures in brackets indicate the percentage of nursing staff) N=60 As mentioned in table 1.8 the nursing staff carry out some of the work which are

not in their regular profile, however, they have continue to do so because it became

their practice. The nursing staff feel that all these non-nursing work may be a part

of the job description of the doctors or the house keeping staff or the administrative

staff. The usual non-nursing work which the nursing staff regularly perform are

blood transfusion, inserting the IV, giving kidney tray, pulling the Oxygen cylinder,

controlling the visitors, shifting patients one place to another clerical work, election

duty, providing training, lecture to class IV staff etc. It is confirmed that the

hospitals have documents formalising the job descriptions and the staff have seen

such documents but do not have copy of this document in hand. In the absence of

formal guidance or standards the nursing staff are unable to compare or conclude

whether they do more or less or optimal work or the work they do which really is

part of their formal work profile.

96

The nursing staff have a set of responsibilities. These responsibilities could be

achieved by developing better relationships. For making a strong foundation for

creating relationship among the staff there are several methods that are used in

hospitals- one among them is staff orientation. According to table 1.9 nearly 12 per

cent of the staff mentioned that they do not have any formal introduction or

orientation programme when they joined the hospital. Nearly 40 per cent of staff

reported that they were orientated by the Matron and another 35 per cent by their

own colleagues.

Table 1.9 Orientation programme for the nursing staff

At time joining orientation conducted by

Present designation


Supervisor 24 (9.1) 11 (20.8) 35 (11.0)Matron 108 (40.9) 18 (34.0) 126 (39.7)Colleagues 93 (35.2) 16 (30.2) 109 (34.4)None 31 (11.7) 7 (13.2) 38 (12.0)Sister-in-charge 38 (3.0) 91 (1.8) 49 (2.8)Total 264 (100) 53 (100) 317 (100)


The staff orientation is conducted by different persons using different methods at

different points of time. This shows that the hospitals do not have any formal

orientation programme for the staff. Also there is no clear protocol available for the

new recruits in terms of acquaintance with information such as hospital rules,

policies, type of patients and about the hospital. It is perceived that formal

orientation programmes brings better understanding between the employees and

management. Similarly, orientating the staff in the work place is necessary to

improving the social psychological quality of mindset that people have about the

work that they perform. It creates conducive sentiments and emotional feelings that

people associate with their work and thereby improves their work quality. . Finally,

work orientation refers to the symbolic ideas, belief, and emotions that a worker has

about their work-related experience. Work orientation creates a person’s sense of

self. Once the staff get oriented about the working pattern they usually adapt

efficiently to the hospital working system.

97

Organisation of work shift and Duty System

In the study hospitals the duty roster is prepared systematically and distributed in

each ward. According to table 1.10 almost all the nursing staff (98 per cent) say

that there is a duty roster and it is followed without fail. Usually the duty list is

prepared for one full month by the matron. Once the duty roster is ready, it is put in

place and everybody follows the duty roster without fail. In case the staff fail follow

the duty roster they are punished with salary deduction or being marked as absent

for two days known as double day absent. Sometimes it may be difficult for the

staff to follow as per the schedule. In such a situation it is necessary to bring some

flexibility to modify or change their shift timings. It has been found that nearly 68.8

per cent of the nursing staff feel that they had an opportunity to modify or change

the shift for meeting their requirements. The remaining members did not have a

chance to modify their shits for their personal emergencies. Developing quality

work environment needs flexibility in the work schedule.

Since the nursing staff follow the shift system they usually have some problems.

The nursing staff considers that doing shift duty particularly night duty is a major

drawback of nursing profession. Keeping this in view, the nursing staff were asked

to report on this issue. In case they get an opportunity to choose the duty, the

majority of the respondents (nearly 83 per cent as per table 1.10) would prefer to do

morning shift and nearly 16 per cent have given their preference to do afternoon

shift while hardly any staff (less than one per cent) is interested in doing night duty.

It shows that nursing staff are doing their duty mostly against their wishes.

However, their service is needed 24 hours and somebody has to be there with the

patients. So there is no option for staff to withdraw from doing night duty or shift

duties. Another interesting observation is that the younger nurses like to do morning

shift due to their family commitments. Similarly, the elder nurses feel that they

should be given morning shift because they have served several years round the

clock services and at this stage of life in their middle age or old age with the

attendant health issues they should get some relief from doing night shifts. It is very

difficult for the nursing management to handle these issues.

98

Table 1.10 Nursing of Duty system and Flexibility

Variables

Present designation


Do you have duty roster? No (1.9)5 (1.9)1 (1.9)6Yes (98.1)259 (98.1)52 (98.1)311Which shift do you prefer? Morning (82.2)217 (86.8)46 (83.0)263After noon (17.0)45 (13.2)7 (16.4)52Night shift (0.8)2 (0.0)0 (0.6)2Do you have an opportunity to modify or change your shift timings for an emergency or family reason? No (32.6)86 (24.5)13 (31.2)99Yes (67.4)178 (75.5)40 (68.8)218How many times have you been able to avail this? Never (55.7)147 (39.6)21 (53.0)168Sometimes (34.1)90 (39.6)21 (35.0)111Frequently (5.7)15 (9.4)5 (6.3)20Very frequently (4.5)12 (11.3)6 (5.7)18Total (100)264 (100)53 (100)317


Shift timings and Official break between the shifts

The nursing department maintains proper working system by preparing a duty list,

leave plan and allocating the staff to respective wards. Table 1.11 shows the clear

plan on the timings between each shifts (duration for each shift).

Table 1.11

Shift Timings S.N Duty Shift Timings Applicable to Remarks

1 Morning Shift 7.00 am - 2.30 pm Staff Nurse Circle duty staff

2 Evening Shift 2.00 pm – 9.30 pm Staff Nurse Circle duty staff

3 Night Shift 9.00 pm – 7.30 pm Staff Nurse Circle duty staff

4. General Shift 8.00 am – 4.00 pm Staff Nurse Only for OPD/OT

5 General Shift 7.00 am – 3.00 pm Sister in charge S/I of each ward/OT

6 Evening Shift 1.00 pm – 9.00 pm Sister in charge S/I evening

supervisor

7 Evening Shift 9.00 pm – 7.00 am Sister in charge S/I Night duty

supervisor

(Sources: Attendance registers of nursing staff, at the matron office)

99

Sister in charge and senior staff nurse usually do general duty which consists of 8

hours. In addition to some of the staff nurses who are young mothers, older nurses

with lots of years of experience (on the ground of health problems) are given

general duty as per the decision of matron office.

The nursing staff is expected to work a minimum of 24 days in different shifts in a

month and the remaining 6 days are given as day-off generally in between a shift

change. Each shift has specific duration for example night shift has 10 hours duty

and day duties usually last 7.30 hours. The system is rotated to ensure that all the

staff nurses and the sister incharge shall undergo a similar system for every month.

The details are presented in the table as given below:

Table 1.12 Work shift hours for a Month

Sl.No Duty

shift No. of days

Actual work hours of Staff Nurse

Actual work hours of Sister in-charge

1 Night shift 06 days 10 hours per shift 10 hrs x 6 days = 60 hours

10 hours per shift 10 hrs x 6 days = 60 hours

2. Morning shift

12 days 7 and half hours per shift 7.5 hrs x 12 days = 90 hours


3. Evening shift

06 days 7 and half hours per shift 7.5 hrs x 6 days = 45 hours


4. Day off 06 days - - Total 30 days 195 hours in a month Total hours = 204 – 16 =

188 hours* * Half day leave @4 hours per day for 4 weeks (4hrs x 4 days) =16 hours (Sources: Duty Roster, at the matron office)

Circle duty system is common in all the hospitals. The sister incharges do mostly

morning shift and night duty weekly once. The night duty may increase or decrease

depending on sister incharges positions available in the hospital. As per the current

nursing duty roster the nursing staff do which include day and night duty for 195

hours and sister incharge 188 hours in a month. The sister in-charge is provided

with half a day leave every week in addition to their four offs in a month.

Official Break: Break is essential for the staff in between the hectic work schedule.

It is found that different practices are followed in the hospitals. In fact there is no

clear rule which specify the break between the work shifts. In this regard nearly

100

58.4 per cent of the nursing staff reported that they have the privilege of getting

official break during shift and another 38.5 per cent of the staff reported that they

have no official break during the shift. The details are presented in Table 1.13

Number of breaks during the shifts: Nearly 59 per cent of the respondents enjoy

one break in the morning shift as per table 1.13. Nearly 99 per cent say that there is

no official break in the afternoon and night duty. It shows that there is a lack of

clear guidance regarding providing breaks to the nursing staff in the hospitals. The

reason for not providing official break is because the nursing staff are expected to

provide patient care 24 hours and leaving the patients may hamper the treatment.

Therefore, there is no official break or fixed time of break during the shift. A

practice followed in the hospitals is that if there is an adequate number of staff

present in the ward, there is an increased likelihood for the staff members to get a

break during their shifts. Also there is a possibility of getting a break if there is a

reliever who will come and take over the duty. Even though there is no official

break the nursing staff are permitted to take a break anytime during their shift

unofficially when there is less work load in the ward.

Duration of Break: The respondents have indicated that the mean duration of

break is 31 minutes in the morning shift. It ranges between15 minutes to 60

minutes. It is very important to note the break is given only in the morning shift and

general shift and there is no break in the afternoon or night shift.

Table 1.13 Break in between the shifts and frequency of breaks

Opportunity for getting break between the shifts

Present designation Total Staff Nurse Sister incharges

No (39.8)105 (32.1)17 38.5)122Yes (56.8)150 (66.0)35 58.4)185Morning shift: No. of Breaks No break (40.9)108 (30.2)16 39.1)124One break (59.1)156 (69.8)37 60.9)193Average Duration of each-Morning Shift 15 minutes (0.6)1 0.0)0 0.5)130 minutes (95.5)149 86.5)32 93.8)18140 minutes (3.2)5 13.5)5 5.2)1060 minutes (0.6)1 0.0)0 0.5)1Total (100)264 100)53 100)317


101

Practical constraints and suggestions regarding break: The staff members are unable to enjoy the break because it does not have official

status. On the other hand, even if the hospital allows them to take a break; it would

not be possible for them to take a break because of the non-availability of relievers

for the staff. In addition to that if the nursing staff work load is heavy in the busy

wards, the patients need constant attention of the nursing staff and it would be

difficult for the nurses to move away from their wards. These are the practical

constraints which affect the nursing staff and do not allow them even a break to

relax form their work pressures.

The staff nurses and sister incharges suggest that one break of 30 minutes should be

provided in each shift or at least 15-30 minutes should be given as a break in

between the shift particularly in the afternoon shift. Nursing staff also should be

given break like any other administrative staff. Some of the staff feel that the

present system of giving one break in the morning shift and no breaks in the other

shifts should be continued. However, it is not acceptable to some of the other staff

members. Furthermore, some of the nursing staff suggest that the break should be

according to the work load and if there is less or no work load then the staff is likely

to get a break. Giving official breaks or increasing their frequency may affect

patient care. There is a lack of unanimous consensus among the nursing staff about

the changes needed in the break system.

Double duty

In BMC hospitals double duty is common. Double duty means the staff has to

continue to work one shift after another for two shifts in single day. In other words,

the staff does two work shifts without having any break. In the study hospitals a

majority of the staff (80 per cent) reported that they do double duty in a single day.

The double duty is a convenient tool for the nursing management to make up for the

immediate shortage of staff or absenteeism. There are various reasons for the staff

doing double duty in the hospitals, such as shortage of workforce, increased work

load in the hospital (work load increases whereas actual number of staff is remain

the same), staff members’ frequent absenteeism either for short period or due to

102

long leave, lack of substitutes to meet the additional staff requirements, etc. It is

observed that at a given point of time nearly 10 to 15 per cent of the staff are on

long leave. Also, the double duty depends on seasonal requirements, particularly

during the children’s Board examinations, summer and festival seasons as during

this period a large number of staff apply for leave. The hospital management finds it

very difficult to put strict rules in place against the staff wishes. Nearly 66.7 per

cent of the staff report that they do double duty occasionally, 29.6 per cent say that

they are required to do so once or twice in a month and another 3.6 per cent say that

they have to do double duty every week. It shows that double duty has become

inevitable in the hospitals. If the hospital avoids double duty then the patient care

may get affected due to non-availability of the staff during the shift. At the same

time if the double duty norm continues, the staff get tired and there is a possibility

of adverse effects in the ward like compromise on quality of patient care and lack of

attention given to the patients. Also there is a possibility that with less number of

staff posted in the ward the staff present have to take on the entire work load and

work under a lot of pressure.

Table 1.14 Double duty, compensation for double duty

Variables

Present designation


Are you doing double duty? No 44 (16.7) (37.7)20 64 (20.2)Yes 220 (83.3) (62.3)33 253 (79.8)How often do you do double duty? Weekly once 9 (4.1) (0.0)0 9 (3.6)Monthly once /twice 64 (29.1) (21.2)7 71 (28.1)Occasionally 47 (66.8)1 (78.8)26 173 (68.4)In what ways is the double duty was compensated? Day off 224 (97.8) (100.0)42 266 (98.2)Monetary 5 (2.2) 0.00 5 (1.8)Total 264 (100) 53 (100) 317 (100)

(Figures in brackets indicate the percentage of nursing staff) N=317 The staff double duty is compensated by providing a compensatory off. There is no

monetary support for doing double or extra duties in the hospital. Providing

compensatory off has its own side effect in that a staff who does double duty would

take the compensatory off along with her regular off creating a larger gap in a

103

situation already overwrought with lack of human resources that led to the existing

staff having to do double duty in the first place. This means the cycle of double

duty will never end. Since there is a heavy shortage of nursing staff in the hospital

and very less scope for avoiding double duty in the hospitals it becomes necessary

for the hospital to keep attractive incentives for the staff who do double duty. In

this way the hospital can avoid work pressure among the staff and would able to

cope with the situation.

Nursing work force, work load and job rotation

Hospitals are facing an acute shortage of work forces. There are several reasons for

this shortage. The shortage of staff really affects the patient care, however, the

hospitals do try to provide patient care with the available resources. On the other

hand, it may be difficult to provide even minimum level care when the number of

staff is reduced beyond a certain limit as it creates distress among the staff. At this

stage it has become very important to look at the work force of the study hospitals.

BMC has provided certain guidelines with regard to minimum staffing requirement

i.e. sanctioned posts for these hospitals. Sanctioned post is the minimum number of

staff who should be available to accomplish the tasks (work load) of the hospitals.

The details of staff position in the study hospitals are presented in table 1.15 There

is always some vacant position exist in the hospitals. The current situation in the

study hospitals is presented in table 1.15.

Table 1.15

Nursing workforce in the Study Hospitals

Hospital

Staff nurse Sister in charge Total

SP FP VP SP FP VP SP FP VP Bhagawathi Hospital, Borivili 135 124 11 19 17 2 154 141 13 V N Desai Hospital, Santacruz 81 74 7 13 10 3 94 84 10 K B Bhabha Hospital, Kurla 80 70 10 12 12 0 92 82 10 M T Agarwal Hospital, Mulund 51 43 8 15 12 3 66 55 11

Satapti Hospital, Govandi 67 56 11 8 7 1 75 63 12

Total 414 367 47 67 58 9 481 425 56 SP=Sanctioned posts, FP= Filled posts, VP= Vacant Posts Sources: Hospital records of study hospitals

104

The study hospitals have an overall of 481 sanctioned nursing posts, 433 filled posts

and 56 vacant posts which include both staff nurses and sister incharges. The

overall vacant posts constitute nearly 11.3 per cent. Among the staff nurse nearly

8.8 per cent are vacant and of the sister in-charge 13.4 per cent positions are vacant.

It is very important to note that the sanctioned posts are the minimum needed staff

for providing patient care which is decided by the competent authority at the higher

level, however, in not one hospital has it been filled completely. This has a direct

impact on the ward services and when the patient need care nursing staff may not be

available to help them. In other words, the staff plan the services and do the services

and not as per the patient’s needs because they have to give basic care to

everybody and if they have additional time they may see to the supplementary

needs of the patients. The staff shortage is a universal problem all over the country

and world. The majority of the nursing staff (90 per cent) have reported that there is

a shortage of staff nurses in the hospitals which lead to various problems not only

for the staff, but also for the patients. The nursing staff position available is shown

chart-4.

Chart-4 comparison of sanctioned posts, filled posts and vacant posts

0

50

100

150

200

250

300

350

400

450

Staff Nurses SisterIncharges

Sanctioned postsFilled PostsVacant Posts

Furthermore, a considerable number of staff have expressed their feelings that

shortage of staff has created more work pressure and health problems for the staff.

Yet, there is another important aspect need to be examined is comparing the

sanctioned positions with nursing council norms. The number positions needed for

each hospital is presented in table 1.16.

105

Table 1.16 Nursing staff requirement as per the nursing council norms

Hospital Number of beds

Ope

ratio

n th

eatr

e Average OPD per

day

Nursing staff requirement as per

MCI norms including 30 per cent reserve To

tal

General Critical Nursing staff

Sister in charge

Bhagawathi Hospital, Borivili

373 12 13 1019 268 64 332

V N Desai Hospital, Santacruz

284 - 5 1333 160 46 206

K B Bhabha Hospital, Kurla

306 - 4 1241 165 50 215

M T Agarwal Hospital, Mulund

225 10 8 643 172 41 213

Satapti Hospital, Govandi

210 10 9 1095 175 41 216

Total 1398 52 39 5331 940 242 1182 While comparing the actual posts (filled) positions with nursing council norms the

number of staff needed is 200 per cent. The details of nursing norms enclosed in

appendix 5. When comparing the sanctioned positions with nursing council norms,

the sanctioned post is an average of 40.6 per cent of nursing council norms,

similarly, comparing the filled posts and the nursing council norms, the filled posts

amount to a mere 36 per cent of the nursing council norms. A comparative table is

presented along with graph in table 1.17 as given below.

Table 1.17 Comparison between the sanctioned posts with nursing council

norms

Positions Staff Nurses Sister incharges Total

Sanctioned positions 414 67 481

As per nursing council norms 940 242 1182

106

0100200300400500600700800900

1000

Staff Nurses SisterIncharges

Sanctioned posts

Filled Posts

Staff needed asper nursing councilnorms

Keeping the above data in view, it becomes necessary to examine the staff-patient

ratio in actual situations. The data that has been collected through the structured

questionnaire is presented in table 1.18. In the hospitals the staff allotment is based

on the wards and number of beds. The wards are categorised as: small ward about

25 beds, medium size 26 -35 beds and bigger wards up to 45 beds. It is observed

that in many hospitals renovation work is in progress so the hospital authorities

have combined two wards or three wards together. Sometimes there would be

possibilities of allotting the staff based on number of patients in case the workload

increases. The staff are distributed among Operation Theatres, Critical Care Units,

the various types of Wards and Out Patient Services. It is found that nearly 29 per

cent of staff are allocated to the operation theatre services while 71 per cent are

distributed among the wards and the OPD services. During the interviews in the

study hospitals the nursing staff managed a number of patients. The details are

presented in table 1.18. The nursing staff report that nearly 18 per cent attend to less

than 10 patients while another 16 per cent attend 21 to 30 patients in a single shift.

Moreover, nearly 10 per cent attend to 31 to 40 patients in their shift. The mean

current nursing staff and patient ratio is 1:13 i.e. one staff member is responsible for

thirteen patients. Ideally, 1 staff is to 5 patients is the required ratio in every shift.

But in the sample hospitals the number of patients for each nurse to care for is much

higher. It shows that the nursing staff are really required do more work and handle a

large number of patient in their shifts so that they concentrate on the minimum

patient care essential for the wellbeing of the patients.

107

Table 1.18 Number of patients seen by nursing staff during their the shift

In your duty you over see-Patients Staff NursesSister

incharges TotalOT services 75 (28.4) 23 (43.4) 98 (30.9)Less than 10 pts 49 (18.6) 8 (15.1) 57 (18.0)11-20 pts 42 (15.9) 6 (11.3) 48 (15.1)21-30 pts 43 (16.3) 7 (13.2) 50 (15.8)31-40 pts 29 (11.0) 3 (5.7) 32 (10.1)41-50 pts 19 (7.2) 4 (7.5) 23 (7.3)50 pts and above 7 (2.7) 2 (3.8) 9 (2.8)In your duty you over see-Wards OT 67 (25.4) 21 (39.6) 88 (27.8)1 Ward 180 (68.2) 23 (43.4) 203 (64.0)2 wards 12 (4.5) 4 (7.5) 16 (5.0)3 wards 5 (1.9) 5 (9.4) 10 (3.2)Total 264 (100) 53 (100) 317 (100)


The hospitals have no provision to provide extra staff when the workload increases

in the ward and other areas. As seen in Table 1.19, nearly 68 per cent of nursing

staff mentioned that the hospitals do not provide any extra staff in such situations. It

is to be noted that the hospitals are already facing shortage of staff and there is no

possibility of providing extra staff.

Table 1.19 Additional staff are provided if the work load increases

Does the organisation provide for extra staff if workload increases? Staff Nurses Sister incharges TotalNo 179 (67.8) 37 (69.8) 216(68.1)Yes 85 (32.2) 16 (30.2) 101(31.9) 264 (100) 53 (100) 317 (100)

(Figures in brackets indicate the percentage of nursing staff N=317

All the study hospitals follow the strategy of job rotation for a specific period of

time. Job rotation shall help the staff gain experience in a variety of conditions and

also lead to the acquisition of multi-skills. This also helps the hospital make an

arrangement for substitute in any ward irrespective of staff crunch so that the work

will not suffer. Job rotation has created an opportunity for the nurses to work in

Operation Theatre, Critical Care Services and special and general wards. As seen in

Table 1.20 nearly 90 per cent of staff say that they have been rotated on the job

every year and another 5 per cent reported that they are rotated in once in two years.

108

At the outset the job rotation fulfills the aim of the nursing staff of being

professionals with multi skills.

Table 1.20 Nursing staff Job Rotation

How frequently you are shifted to one ward to another? Staff Nurses

Sister incharges Total

Daily 4 (1.5) 3 (5.7) (2.2)7

Yearly 259 (98.1) 28 (52.8) 287

(90.5)One in 2 yrs 1 (0.4) 14 (26.4) 15 (4.7)One in 3 yrs 0 (0.0) 8 (15.1) 8 (2.5) 264 (100) 53 (100) 317 (100)


Work activities and Time spent for each activity

Nursing staff are engaged in several activities during their duty (single shift) which

is, generally, 7 hours 30 minutes in a day. Some of the activities that are performed

are directly connected with patient care and some of the activities are indirectly

associated with patient care. The staff nurse utilises nearly 50 per cent of her time

for direct patient care. The rest of the time is spent on other activities. The non-

nursing work can be done by others instead of the nursing staff so that the nurse can

devote her full time to patient care. If such an arrangement is made the current

nursing shortage can be managed to some extent.

Table 1.21 Time Utilisation by Staff Nurse

Activities performed by Staff Nurse Time spent for each activity

Out of 450 minutes Per cent

Patient care (medication, communicating with patients, bed making, handing over taking over, rounds with doctors, planning of work)

225 50

Clerical work (writing a case file, Preparing report, indent, etc) 71 16

Inventory management, ,collecting, checking items from stores etc 31 7

Telephone conversation for work purpose 14 3 Handling visitors / relatives and others 27 6 Internal training (case discussion, and other learning) 23 5 Traveling to various places in the hospital for work purposes 18 4

Break (coffee, tea, and lunch) 27 6 Talking to the friends, and colleagues other than the work matters 14 3

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The sister in-charge plays vital role in organising, supervising, implementing and

evaluating work at the ward level and in some cases the entire hospital. Usually the

sister in-charge does an eight hours duty. The table below presents the various

activities performed by the sister in-charge. The sister incharges are senior staff and

they are engaged in patient care as well in guiding the staff. Sometimes they are

given the responsibility of managing particular ward(s). The sister in-charge spends

nearly 42 per cent of her time on nursing care activities and the rest of the time is

spent on other works that could be easily managed by a non-nursing staff member.

In private hospitals there some posts such as patient care coordinators or nursing

aids to serve the patients and assist the nursing staff in the ward. In such situations

the nursing staff spend their valuable time to only on patient care activities and the

other duties are managed by the other staff work in the ward.

Table 1.22 Time Utilisation by Sister incharges

Activities performed by sister in charge

Time spent for each activity Out of 450 minutes

Per cent out of 100

Preparing duty list, allotment staff, organising staffing for day to day, supervisory function, discussion with patients and relatives, supervision of night duty and afternoon duty for whole hospital etc.

202 42

Clerical work )writing a case file, Preparing report, indent, etc 86 18

Inventory management, ,collecting, checking items from stores etc 43 9

Telephone conversation for work purpose 19 4 Handling visitors / relatives and others 29 6 Internal training )case discussion, and other learning 34 7 Traveling to various places in the hospital for work purposes 24 5

Break )coffee, tea, and lunch 29 6 Talking to the friends, and colleagues other than the work matters 14 3

Nursing effective working hours

The nursing staff are provided with the following leaves

Casual Leave 20 days in a year

Earned Leave 30 days in a year

Sick Leave 15 days in a year

Maternity Leave 90 days for a delivery

Weekly off 72 days for a year

Half Pay Leave 20 days for a year

110

In addition to the above there is a provision for abortion leave for the staff and two

permissions for at least 1-2 hours of absence each is granted to the staff in a month.

The sister incharges and senior staff get a weekly one day and half day leave

respectively. Considering the number of off-days and other requirements the

nursing staff’s effective working hours is calculated.

Staff Nurse

Total number of days available in a year = 365 days

Number of days leave in a year 147 days

Net working days = 218 days

As per the above analysis the staff nurses devote 50 per cent of the time for patient

care so the net working time goes to patient care is 109 days i.e. 30 per cent of the

time in the year to patient care, but the staff are paid for the full year. In this case it

is important to note that the working system, organisational ability and old practices

are the primary instruments responsible for not using the working days of staff

efficiently.

As per the above analysis the sister incharges devote 42 per cent of the time for the

core purposes and direct work related issues so the net working time for patient care

is 92 days i.e. 25 per cent of the year for patient care but the staff are paid for the

full year. In this case, too it is important to note that the working system,

organisational ability and old practices are primary responsible instrument for not

using the net working days of staff.

Considering the actual situation, the nursing staff have reported their satisfaction

with regard to time devoted to nursing supervisory and patient care processes. It is

understood that the nursing staff do not allot sufficient time to patient care. It is also

evident in Table 1.23 that only 32 per cent of the staff feel that the time devoted to

patient care is satisfactory and the rest of the respondents feel that non-nursing work

takes more time. Also some of the nursing staff feel that due to the heavy work load

the time spent on each patient is nominal. There are two issues affecting the nursing

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staff satisfaction with regard to time devoted the patient care process: (1.) There are

more non nursing jobs and (2.) Inadequate time devoted to the patients due to work

pressure.

Table 1.23 Nursing staff satisfaction regarding the time devoted to patient care

What extent do you satisfied with the time you give for patient care?

Present designation


Not at all (6.8)18 (5.7)3 (6.6)21To some extent (62.5)165 (56.6)30 (61.5)195To a large extent (30.7)81 (37.7)20 (31.9)101Total (100)264 (100)53 (100)317


Analysis of nursing tasks

Nursing tasks are considered to be significant ones. There is no doubt that the

nursing staff really contribute to the patient care process meaningfully. However,

the nursing staff do many jobs which are not specific to their profession. In such

cases it may affect the quality of nursing specific work as well decrease the

intensity level of their work. Also there is a scope for developing the perception a

low value is assigned to the nursing profession. Every nurse can choose to do the

job that challenges, is interesting and makes her feel proud. If the staff have an

opportunity to do such kinds of job she is motivated, satisfied and achieves a good

performance. Theoretically speaking the workplace where the employees perform

high complexity tasks shows that there is very low absenteeism Turner and

Lawrence identify five job characteristics and their relationship to personal and

work outcomes. According to the experience and practice of the staff members on

the job activities may rate each characteristic high or low.

1. Skill variety: the degree to which the nursing job requires a variety of

different activities so the nurse can use a number of different skills and

talent

2. Task identity: the degree to which the nursing job requires completion of a

whole and identifiable piece of work.

3. Task significance: the degree to which the nursing job has a substantial

impact on the lives or work of other people

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4. Autonomy: the degree to which the nursing job provides substantial

freedom, independence, and discretion to the individual in scheduling the

work and in determining the procedures to be used in carrying it out.

5. Feedback: the degree to which carrying out the nursing work activities

required by the nursing job results in the individual obtaining direct and

clear information about the effectiveness of her performance.

These job characteristics such as skill variety, task identity, task significance,

autonomy and feedback or low feedback on the job of nursing can be rated as low

or high for example low skill variety or high skill variety on so on.

Skill variety

As evident in Table 1.24 nearly 69.4 per (very frequently 30.3 per cent and

frequently 39.1 per cent) of staff feel that their job provides opportunities to update

their skills. When the job demands very frequent updates the nursing staff get

involved with a number of jobs or a variety of jobs that could also involve a new

one. In such a case they would require a very high level of skills variety to

accomplish such tasks. Even experienced nurses report that there are many changes

in nursing techniques, work automation and computerisation etc. which are really

challenging for them. In fact, they should be able to tap into their reservoir of

knowledge to tackle the new tasks or use it as a stepping board to update their

knowledge to tackle such tasks. The nursing profession has been undergoing many

changes and demands always high skill variety.

Task identity:

Table 1.24 depicts that nearly 65 per cent (very frequently 24.6 per cent plus

frequently 40.4 per cent) of the staff feel that they are engaged in important jobs

which are identifiable with their own contribution. Since nursing is an activity that

lasts for 24 hours it is mandatory that in each shift the respective nursing staff

accomplish their tasks within their shift timings. Individual work is well-

coordinated and is incorporated in the whole patient care process and it is possible

to identify the particular staff member who is responsible for a particular procedure

which impacted patient care positively. Thus, while the staff members accomplish

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patient care through collective efforts, every staff member’s contribution is

identifiable in the entire patient care process. The task identity brings significance

clarity on the efforts of nursing patient care.

Task significance:

As seen in Table 1.24 nearly 64 per cent (very frequently 40.70 per cent and

frequently 23.70 per cent) of the staff feel that the nursing job (current work) makes

them feel proud. The nursing staff usually serve the needy and are responsible for

the essential patient care. Patient care has always been considered a significant job.

However, while it is generally expected that the nursing staff would consider the

task nursing highly significant, only about 64 per cent of the staff described their

job thus. This finding is in line with the nursing staff’s opinion about the nursing

profession as lacking when it comes to commanding respect and getting recognition

within the hospital despite years of experience. However the task significance

directly associated with necessity of such tasks to be performed as well the outcome

of such tasks.

Autonomy

That 59 per cent (very frequently 23.70 per cent plus frequently 35.30 per cent) of

the nurses feel that they enjoy a high degree of autonomy to decide their work

schedule and carry out their routine work is also seen in Table 1.24. The job high

autonomy leads to responsibility-oriented staff and ensures that the staff take

personal responsibility for the results. On the other hand, as nearly 41 per cent of

the nursing staff hope that they are not provided with adequate autonomy and in this

case the staff may not take personal responsibility for their own actions. It may be

possible that these nursing staff did not have such exposure. In fact, the nursing

staff are restricted to decisions regarding very few aspects of their routine work.

The staff should follow the instructions of doctors, nursing administration.

Feedback

As visible in Table 1.24 nearly 52 per cent (very frequently 20.8 per cent and

frequently 31.5 per cent) of the staff feel that they get feedback from their superiors

from time to time. A large number of staff, nearly 48 per cent, state that there is no

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feedback from their superiors. In fact, it is observed that there is no proper system

of monitoring or checking the work done by the staff nurses in the ward. In such an

organisation there is no way to provide feedback to the staff and this also adds to

the difficulty of understanding the nursing staff’s performance from the

management point of view.

Table 1.24

Nursing Job characteristics

Frequency of updating skills and abilities (Skill variety)

Present designation


Very frequently 80 (30.3) 16 (30.2) 96 (30.3)Frequently 103 (39.0) 21 (39.6) 124 (39.1)Some times 63 (23.9) 10 (18.9) 73 (23.0)Never 18 (6.8) 6 (11.3) 24 (7.6)Task accomplished recognisable easily or identified by you or others (Task Identity) Very frequently 59 (22.3) 19 (35.8) 78 (24.6)Frequently 112 (42.4) 16 (30.2) 128 (40.4)Some times 69 (26.1) 12 (22.6) 81 (25.6)Never 24 (9.1) 6 (11.3) 30 (9.5)Tasks which makes feel proud of being nurse and the task being useful to the hospital Very frequently 105 (39.8) 24 (45.3) 129 (40.7)Frequently 63 (23.9) 12 (22.6) 75 (23.7)Some times 54 (20.5) 6 (11.3) 60 (18.9)Never 42 (15.9) 11 (20.8) 53 (16.7)Frequency of job allows to decide the work schedule, and plan your work with freedom Very frequently 56 (21.2) 19 (35.8) 75 (23.7)Frequently 98 (37.1) 14 (26.4) 112 (35.3)Some times 63 (23.9) 11 (20.8) 74 (23.3)Never 47 (17.8) 9 (17.0) 56 (17.7)Frequency of job/superiors provides feedback about the staff progress and performance Very frequently 52 (19.7) 14 (26.4) 66 (20.8)Frequently 86 (32.6) 14 (26.4) 100 (31.5)Some times 89 (33.7) 17 (32.1) 106 (33.4)Never 37 (14.0) 8 (15.1) 45 (14.2) 264 (100) 100(53) 100(317)

(Figures in brackets indicate the percentage of nursing staff) N=317 Table 1.24(A) clearly evidences that nearly 80 per cent of the staff get oral

feedback. In the absence of a formal mechanism of feedback system the nursing

staff have no way to understand their level of performance.

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Table 1.24 (A)

Method of feedback to the nursing staff Method the feedback was delivered

Present designation Total Staff Nurse Sister incharges Staff Nurse

Oral 215 (81.4) 39 (73.6) 254 (80.1)Written 0 (0.0) 2 (3.8) 2 (0.6)Both 12 (4.5) 4 (7.5) 16 (5.0)No feed back 37 (14.0) 8 (15.1) 45 (14.2) 264 (100.0) 53 (100.0) 317 (100.0)


Meaningfulness of nursing work

The meaningfulness of nursing work means the nursing staff should feel that at the

end of day they have done a useful job and it has really benefited the patients. The

meaningfulness of a job is identified by adding the three variables skill variety, task

identity, and task significance, if these three characteristics exist in the job. It is then

possible to predict whether the incumbent will view the job as important, valuable,

and worthwhile. The following table represents the meaningfulness of nursing

work:

Table 1.25 Meaningful job

Meaningfulness of job High Low TotalSkill Variety 214 (69 ) 103 (31 ) 317 (100)Task Variety 206 (65 ) 111 (35 ) 317 (100)Task Identity 204 (64 ) 113 (26 ) 317 (100)


It is clear in Table 1.25 that the nursing staff have rated that the tasks which they

perform involves high levels of skill variety (69 per cent), task variety (65 per cent)

and task identity (64 per cent). While the figures are not very high, it can be

concluded that the nursing staff consider that their current job is meaningful and

that nursing does involve meaningful work.

Motivating Potential Score (MPS)

The motivating potential score is computed to identify the significance of the

nursing task. It is computed by adding the scores of skill variety, task identity and

task significance and divide this sum by three and multiply the resulting figure with

autonomy and feedback. The formula for computing MPS is as given below:

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MPS = skill variety, task identity and task significance x Task identity x Feedback

3

After computing the score, it is further recoded as high or low in the SPSS

programme as is shown in Table 1.26.

Table 1.26

Motivating Potential Score Motivating Potential Score Per centLow 145 (45.7 )High 172 (54.3 )Total 317 (100.0)


Jobs that are high on motivating potential score must be high on at least one of the

three factors that lead to experienced meaningfulness (skill variety, task identity and

task significance), and the score must be high on both autonomy and feedback. As

found in Table 1.25 all three factors combine together to form meaningfulness (skill

variety, task identity and task significance) an average score is 64 per cent and the

autonomy score is 59 per cent and feedback 52.3 per cent. It is found that the

autonomy and feedback scores are less than the meaningfulness score.

Further, it could be understood that if the motivating potential score is high, the

motivation, performance and satisfaction will be positively affected, whereas the

likelihood of absenteeism and staff turnover will be lessened. As per the scores in

this table the score is on the higher side at 54 per cent so there must be a slight

impact on employee satisfaction, performance and motivation levels.

Furthermore, there is a need to confirm to the extent the MPS has relationship with

absenteeism, the nursing staff’s self perception on performance and their job

satisfaction. Table 1.27 compares MPS with absenteeism and it is found that when

the MPS is high, absenteeism is low (47.7 per cent). This means that the

motivational potential score does lead to lower levels of absenteeism.

In Table 1.27, while comparing MPS with self perception of nursing staff it is

found that when the MPS is high the nursing staff self perception is slightly high

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(50.6 per cent). It shows that the motivational potential score leads to some

improvement in the way they look at their own performance. While comparing

MPS with job satisfaction of nursing staff it is found that when the MPS is

relatively high and the nursing staff job satisfaction is also relatively high (64.5 per

cent). This clearly indicates that a high motivational potential score leads to high

job satisfaction among the nurses. In other words, a well designed and challenging

job would increase job satisfaction among the nursing staff.

Table1.27 Comparison of MPS with absenteeism, Self perception and Job satisfaction


AbsenteeismTotal High Low

Low 67 (46.2) 78 (53.8) 145 (100.0) High 90 (52.3) 82 (47.7) 172 (100.0)Total 157 (49.5) 160 (50.5) 317 (100.0) X2 = 1.178 P=0.277


Self perception

Total Low High Low 68 (46.9) 77 (53.1) 145 (100.0) High 85 (49.4) 87 (50.6) 172 (100.0)Total 153 (48.3) 164 (51.7) 317 (100.0) X2 = 0.200 P=0.654


Job Satisfaction

TotalLow High Low 76 (52.4) 69 (47.6) 145 (100.0) High 61 (35.5) 111 (64.5) 172 (100.0)Total 137 (43.2) 180 (56.8) 317 (100.0) X2 = 9.209 P=0.002


Nursing work related Problems

The nursing staff have to work with various categories of the people in the hospital.

Usually they work with patients, the patient’s relatives, visitors, doctors, class IV

staff, co-workers and the administrative staff. While working with a variety of

personalities they are likely to face some problems. These problems basically relate

to work procedures, systems, work pressure, non-cooperation from colleagues and

misunderstanding about the context. The details of some of the problems are

discussed below.

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Problem faced with patients

When the question about patient related problems was posed to the nursing staff a

majority of the nursing staff replied “In the ward we face many problems from the

patient’s side”. It is a unanimous opinion among the nursing staff. The nursing staff

have highlighted some of the major problems like consumption of alcohol,

shouting at the staff, arguments, asking for special care, smoking, lack of patience,

not allowing completion of certain procedures essential to patient care, lack of

communication, language problems, demanding more time and facilities, frequently

being irritating , creating tension in the ward, not paying their dues for operation

and medicinal purchases, encouraging visitors during non-visiting hours, arguing

about or fighting for medicines that are not available , non co-operation, not

following the given restrictions or procedures, absconding from the ward,

overcrowded wards, lack of satisfaction for the services extended, complaining

about everything, use abusive language, troubling/ threatening the staff with

political connections to satisfy their own whims. Most of these problems are

chronic and recurrent and it is very difficult to curb them. The staff need more

support from the management to solve many of these problems. Also, the nursing

department should focus on the issues which affect the nursing staff directly or

indirectly.

Problems faced with Patients’ relatives

The patient relatives present more problems than the patients themselves. The usual

problems are vociferous arguments due to non-availability of medicines, arrogant

behaviour, involving political bigwigs (corporators), visiting at any time and not

following the visiting hours schedule, using foul language, disturbing other patients

in the ward, not attempting to understand the explanations given by the nursing

staff due to lack of basic knowledge and yet interfering with the nursing work,

fighting with the nursing staff, not listening to the requests of the staff, over-

crowding, etc. These problems are daily affairs for most of the nursing staff. In fact,

the visitors behave as per their own wishes and norms, disregarding hospital rules.

It is found that the nursing staff have given up on their efforts to control the visitors

in the ward because it has become a routine for the visitors to enter the hospital at

any time and not abide by hospital rules.

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Problems faced with Class IV staff

It is expected that the class IV staff extend complete support to the nursing staff, but

the reality is just the opposite in the study hospitals. The nursing staff face several

problems in day-to-day management of the ward because of the class IV staff.

Some of the usual problems faced by the nursing staff are that the class IV staff

periodically abscond from the work place, absenteeism, engage in open rebellion of

the nurses, do not follow given instructions, consume alcohol while on duty, sleep

while on duty, don’t follow the activities logically, , exhibit arrogant behaviour,

indulge in unacceptable practices that are unethical at times , etc. It is observed

that there is a strong union for class IV staff in every hospital. It is therefore

difficult to take any kind of disciplinary action against them. The current situation

seems to be uncontrollable and at any given point of time the hospital management

can face serious problems due to the lack of cooperation and support from the class

IV staff in the study hospitals.

Problems faced with peer groups

The nursing staff stated that did face some problems with their colleagues. The

usual problems include colleagues reporting late for duty or substitution ,

occasional absenteeism which leads to double duty, lack of communications

resulting in misunderstandings and shortage of staff which adds to the work

pressure, becoming sick, inability to leave for long periods of time .

Problems faced with doctors

The doctors usually come late and (re)write the patient care orders which affect

routine work of the nursing staff. The late arrival of most doctors leads to the nurses

having to answer patients’ queries that might lead to arguments and fights.

Sometimes there is no support extended to the nursing work by the doctors for work

related issues. Some of the young doctors do not understand the ground reality of

the system wherein the nursing staff faces a few problems with both the

administration and the patients.

120

Problems faced with administration

The administration fails to provide even the minimum work facilities. They are

unable to understand the practical issues that the nurses have to grapple with. They

are unable to organise the required supplies for the patient care, for which the

nurses bear the brunt of the patients’ ire. They are often uncooperative even on

work related matters and maltreat the nurses at times.

Supervisory Responsibilities

Sister in charge supervisory responsibilities

The Sister incharges are responsible for supervising the nursing staff in the ward.

The number of persons to be supervised based on the ward size and the number of

staff they supervise because of the nursing staff allocation is based on the number

of beds occupied in each ward and the ward size.

Table1.28 Number of staff supervised by sister in charge

Supervision of Nursing staff Per cent

Up to 2 staff 14 (26.4)2-4 staff 12 (22.6)5-6 staff 12 (22.6)7 and above 15 (28.3)Total 53 (100.0)(Figures in brackets indicate the percentage of nursing staff) N=317

Usually the senior staff supervises two to seven nursing staff in her wards.

However, in actuality, nearly 28 per cent of the sister incharges supervise more than

seven nursing staff members. When the number of staff needing supervision is high

the sister incharges have to pay more attention to the ward and the management of

the staff nurses in addition to the class IV staff and the management of inventories

in the ward is a huge burden that befalls them. There are several difficulties in

supervising the staff in the hospital. The sister incharges face certain problems at

their level just as the nursing staff face some problems at their level. The sister

incharges have to manage certain issues absenteeism of staff nurses, arrangement

for substitutes, management of long leave for various staff members , ensuring

material supply, checking up on class IV staff availability, coordinating between

the staff and the matron office, etc.

121

Supervisory role of staff nurses

The staff nurses have to supervise some of the other staff nurses and the class IV

staff while discharging their duty. It is found that a considerable number nursing

staff have put in long years of services but did not get promoted and such nursing

staff are given supervisory responsibilities establishing them as senior nurses. The

senior nurse position is not an official one. In this case the senior nursing staff shall

supervise the nursing staff. Nearly 48 per cent of the senior staff supervises one or

two staff nurses and the class IV staff. Nearly 10.6 per cent of the staff nurses

supervise 5-6 class IV staff during their duty hours. It is observed that supervisory

responsibilities lead to tension. Some of the usual problems associated with class IV

staff supervision are absconding from the work place, disobedience, drinking and

sleeping while on duty, trouble-making, and non-cooperation.

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PART-2. WORKING CONDITIONS AND FACILITIES

This part of the chapter is based upon findings and analysis of working conditions

and facilities provided by the hospitals for the nursing staff to carry out the

functions.

2.1 Physical Facilities

Healthcare delivery is a dynamic process which involves use of appropriate inputs.

The inputs include various resources like human resources, material resources and

financial resources. The human resources concern doctors, nursing staff, technical

staff, maintenance staff, housekeeping staff, etc. The material resources include

medical, surgical and consumable items and other technical support necessary for

patient care. In order to provide better patient care hospitals need to maintain their

equipments and possess the right quantity of material supply Quality material made

available at the right time is very important for proper healthcare delivery. At the

same time, adequate facilities like drinking water, sanitation, communication

facilities will help the staff members achieve patient care goals. The hospitals

should be in a position to provide these items in a timely and efficient manner. The

non-availability of physical facilities may affect healthcare delivery as well as bring

down the performance levels of the nursing staff and their job satisfaction.

Keeping this in view, a structured questionnaire was administered to the nursing

staff to understand the current situation with regard to material availability. The

nursing staff’s comments on the status of physical facilities availability in the

study hospitals. is presented in Table 2.1

Equipment availability is one of the major concerns in the study hospitals. All these

hospitals have been provided with the bare minimum equipments which are

essentially needed for providing patient care. However, the respondents working in

different departments reported that there has been inadequate provision of

equipment to meet even the minimum requirement of patient care. The majority of

the respondents, nearly 80 per cent, feel that there is a need for an increase in the

availability of equipments as well as an improvement in their functionality and

maintenance to provide adequate patient care. It should be noted that there is a

123

slight difference of opinion between the staff nurses and the sister incharges in

terms equipment availability and that the sister incharges are more positive than the

staff nurses.

Table 2.1

Grading the facilities available in the hospital

Physical Facilities Grading Staff Nurse Sister incharges

Total

Equipment Not at all 12 (4.5) 0 (0.0) 12 (3.8)To some extent 212 (80.3) 43 (81.1) 255 (80.4)To a large extent 40 (15.2) 10 (18.9) 50 (15.8)

Material supply Not at all 7 (2.7) 0 (0.0) 7 (2.2)To some extent 220 (83.3) 45 (84.9) 265 (83.6)To a large extent 37 (14.0) 8 (15.1) 45 (14.2)

Safe drinking water Not at all 67 (25.4) 12 (22.6) 79 (24.9)To some extent 96 (36.4) 17 (32.1) 113 (35.6)To a large extent 101 (38.3) 24 (45.3) 125 (39.4)

Basic sanitation facilities

Not at all 38 (14.4) 7 (13.2) 45 (14.2)To some extent 97 (36.7) 17 (32.1) 114 (36.0)To a large extent 129 (48.9) 29 (54.7) 158 (49.8)

Communication facilities


Place for dining Not at all 59 (22.3) 7 (13.2) 66 (20.8)To some extent 83 (31.4) 14 (26.4) 97 (30.6)To a large extent 122 (46.2) 32 (60.4) 154 (48.6)

Dress changing room Not at all 20 (7.6) 1 (1.9) 21 (6.6)To some extent 95 (36.0) 17 (32.1) 112 (35.3)To a large extent 149 (56.4) 35 (66.0) 184 (58.0)

Total 264 (100.0) 53 (100.0) 317 (100)(Figures in brackets indicate the percentage of nursing staff) N=317

Similarly, it is expected that the supply of material should be regular, without any

delay as well adequate in quantity. The majority of the respondents, nearly 84 per

cent, opinion that the hospital material supply such as medicine, linen and other

consumables are not sufficiently provided by the administration. In other words, the

material supply is inadequate for the staff to manage even the basic requirement of

patient care and definitely not up to the standards that would satisfy the patients

with the level of care that they have been provided with. Here too the sister

incharges exhibit a more positive outlook than the staff nurses.

With regard to other facilities like safe drinking water provided in the hospital only

39 per cent of the staff feel that they have adequate safe drinking water facility.

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Nearly one fourth of staff report that there is no provision for safe drinking water in

their wards. The basic sanitation facilities are adequate according to nearly 50 per

cent of the staff. However, nearly 14 per cent of the staff mentioned that they do not

have any provision for basic sanitation facilities in their wards. There is just a

slight variation in the opinions of the staff nurse and the sister incharges. Nearly 38

per cent of staff nurse and 45 per cent of the sister in charge feel that drinking water

facilities are adequate, and nearly 49 per cent of staff nurse and 55 per cent sister in

charge feel that the basic sanitation facilities adequately provided. It is to be noted

that the staff are working long hours nearly eight hours in day shifts and ten hours

in night shift and sometimes the staff do double duty and need to use these

facilities. The absence of such facilities situation lead to poor hygiene and also

affect the health of the staff. In addition to the above, there is a possibility for lack

of sanitation to lead to an increase in sources for infection in the very place where

patients are in a condition most susceptible to them. It has been observed that in the

initial planning of the hospital’s basic building structure there had been no

provision made for adequate toilet facilities in some of the important locations

including the wards and in the officers’ rooms. That the current buildings could

support an increase in toilets or water cooler areas is doubtful. However, the

management has to seriously focus on these issues and support the staff as much as

possible.

The communication system is a part of the patient care delivery system in the

hospital. Internal communication facilities like intercom facility, and telephone

connection to local hospitals are extremely essential and useful to the staff while

working in a ward. All the study hospital have made adequate provisions for better

communication facilities in the hospitals. Nearly 57 per cent of the staff feel that

they have been adequately provided with communication facilities.

Nearly 49 per cent of the staff opined that they have adequate place for dining while

21 per cent stated that they do not have any provision for dining facilities in their

ward or in the hospital. There is a significant variation in the opinions of the staff

nurses, nearly 46 per cent, and the sister incharges, 60 per cent, who report that the

dining facilities are adequate. In some of the hospitals the nursing staff are allowed

125

to use the dining hall located in nursing students’ hostel which is little away from

the wards.

Since the majority of the staff stay far from the hospital and travel long distances,

they prefer to come to the hospital in civilian clothes. They prefer changing to their

uniforms before signing the attendance register and this is the norm in all the

hospitals. Nearly 58 per cent of the staff nurses have reported that they have been

provided with changing rooms. Regarding the adequacy of the changing rooms

nearly 56 per cent of the staff nurses as compared to 66 per cent of the sister in-

charge reported that they have adequate changing room facilities in the hospitals.

The overall opinion of the staff regarding the availability of the physical facilities

has been presented in Chart 2.1

Chart 2.1

Nursing staff’s opinion on the physical facilities available in the study hospitals

Nursing staff opinion on physical facilities

4 2

2514 8

217

80 84

36 36 35 31 3516 14

3950 57

4958

0102030405060708090

Equi

pmen

ts

Mat

eria

ls s

uppl

y

Safe

drin

king

wat

er

Basi

c sa

nita

tion

faci

litie

s

Com

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icat

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int

erco

m

Plac

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Dre

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hang

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room

Not at allTo a some extentTo a large Extent

Chat-2.1 indicates that none of facilities meet the compete requirement of the staff.

However communication facilities and dress changing room has exceed above 50

per cent and the other facilities have no significant contribution to the nursing staff

requirement.

In addition to the availability of material, it is also important that the material be

accessible at the right time. Sometimes the material may be stocked in the storage

areas, but they may not be accessible to the staff due to various reasons such as

126

lengthy procedure, lack of authority, or similar reasons. Among the respondents the

sister incharges are expected to have better access to inventory because of

supervisory and administrative requirements. The opinions of the staff nurses and

the sister incharges on physical facilities presented in Table 2.2.

Table2.2

Overall Opinion of nursing staff with regard to physical facilities

Designation

Opinion on Physical facilities availability Total

Low High

Staff Nurse 56.1 43.9 100

Sister In-charge 47.2 52.8 100

Total 54.6 45.4 100

Only 44 per cent of the staff feel that the physical facilities provided rate high in

adequacy whereas 53 per cent of the sisters incharge feel that the physical facilities

availability is high. It is clear that the sister incharges who are of the opinion that

they could access physical facilities are in a better position. This is in line with the

functional authority of the sister incharges. In other words, the sister incharges are

responsible for the management of wards and they directly deal with the

administration and management of material and therefore seem to have fewer

problems with the accessibility of material than the staff nurses.

2.2 Managing the patients in case of non-availability of facilities

Nearly 51 per cent of the staff feel that the patients have suffered due to non-

availability of material in the ward and the hospital. Comparing the staff nurses and

the sister incharges opinions on the issue of the negative effect of non-availability

of physical facilities on patient treatment it is evident that while nearly 50 per cent

of the staff nurses state that patient care suffered due to the non-availability of

material, only 43 per cent of sister incharges feel the patient care was affected by

the non-availability of physical facilities. Overall, 49 per cent of the nursing staff

have reported that patient care suffered due to the lack of availability of material in

the hospitals.

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Table 2.3

Impact of lack of facilities on patient care

Do you have an experience in the past where

due to non availability of material the patient

care was suffered irrespective all your efforts?

Present designation

Total Staff Nurse

Sister

incharges

No 133 (50.4) 30 (56.6) 163 (51.4)

Yes 131 (49.6) 23 (43.4) 154 (48.6)

Total 264 (100) 53 (100) 317 (100)


Since the nursing staff are in direct contact with the patients and they have the

responsibility to provide facilities, guidance and support to the patients during the

course of their entire stay at the hospital, it becomes necessary for the staff to take

some steps to improve the conditions in case the material supply is inadequate or

there is a complete lack of the same in the ward. The nursing staff’s experiences of

managing patients in case there are no medicines or linen or any other facility

available in the ward is shown in Table 2.4.

Table 2.4 Management of patients incase of non-availability facilities

Sl. No. Nursing staff action against non availability of facilities Percentage

1 To follow as per the direction of supervisors/doctors 34

2 Ask the patients or relatives to bring items (medicines, surgical items etc) incase of shortage and they buy from outside

63

3 Only inform superiors and they shall manage 21 4 Incase of need for equipments shall be taken from wards 15

5 Transfer the patient if no service available or higher level of treatment is required to other hospital as per doctor’s instruction

49

6 Give prescriptions to the patients and referring to medical social worker for any other support

76

7 To maintain some material for emergency and take it from other ward

35

In case some of the facilities are not available in the ward or in the hospitals, the

nursing staff ask the patient or their relatives to get such material from outside. If

the facility are complex such as a higher level of treatment , the patients will be

shifted to medical college hospitals because peripheral hospitals are not tertiary care

centers and hence, these hospitals have only limited facilities. It is to be noted that

128

in the study hospitals, facilities like ICU, blood bank, emergency care, diagnostic

equipments like CT Scan, MRI, etc. are not available as per regulatory standards.

2.3 Additional facilities needed for Nursing staff and Patients

Facilities needed for Patients

The nursing staff is of the opinion that there is a need for adequate material supply

for the patients. As indicated earlier, a large number of staff feel that the material

supply is inadequate in the hospitals. Nursing staff feel that some material like

linen, medicines, good diet, disposables, advanced technological machines; number

of beds, antibiotics should be available adequately. Apart from this, the staff also

feel that there is a need for additional services like blood bank, X-ray facilities and

lab services at night, CT scan, MRI, ECG facilities, ICU services, dressing rooms,

drinking water, stationery, blood investigations injections, clean place, proper

educational means and methods for the patients, channels to provide emotional

support to the patients are essential. In addition to the above, free treatment for poor

patients and adequate security guards to control overcrowding in the hospitals

should be provided.

Facilities need for nursing staff

The nursing staff feel that the primary requirement is adequate staff as per staff

nursing council norms (better staff-patient ratio), safe drinking water facilities with

purified aquaguard water, baby-sitting support, bank concession for 2 hours (to do

personal banking work), card swiping instead of manual logging in of arrival and

departure, training and educational facilities for the staff, educational and loan

support for the staff’s children, adequate bathroom and toilet facilities, canteen

facilities, removal of double duty, changing room, locker facilities, common room,

concession on medical treatment, dining room at one or two locations (inpatient or

outpatient areas), official lunch break, rooms for the staff to rest in between their

duty, staff quarters, good salary, additional staff as relievers, more support from

class IV staff, good management, increase in uniform allowance, cabin or locker

for the staff, sick rooms (specialty), time bound promotions, proper nursing stations,

adequate stationeries, suitable duty hours, patient-safety material, staff learning

opportunities, schools of nursing, safety and security for staff particularly from

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alcoholics, respect for the staff, presence of adequate Class IV staff, free tea, dinner

and breakfast for the night staff and reasonable work hours for those on afternoon

and night In addition to the above, the nursing staff expect to be given authority to

discharge (after getting doctor’s discharge instructions) the poor patients (subject to

confirm with proper records as their poor status) in case they are unable to pay at

any time.

2.4 Safety and Security for the nursing staff

Safety and security is very important not only for the staff but also for the patients.

The nursing staff primarily need safety and security in the workplace. Since the

nursing staff provide round-the-clock services, and work in an environment that is

accessible to any and everyone they are naturally concerned about their

vulnerability to physical and psychological threats. Nearly 44 per cent of the staff

have mentioned that they have no confidence in the safety and security measures in

the hospital premises. The nursing staff’s opinion on this issue is presented in

Table 2.5.

Table 2.5 Safety and Security of nursing staff

Security and safety for staff

Present designation


Not at all 118 (44.7) 20(37.7) 138 (43.5)To a some extent 75 (28.4) 17 (32.1) 92 (29.0)To a large Extent 71 (26.9) 16 (30.2) 87 (27.4)Total 264 (100) 53 (100) 317 (100)

(Figures in brackets indicate the percentage of nursing staff) N=317 Safety and security is considered to be an important issue in any work place.

However, the hospitals that are supposed to cater to the well-being of the patients

seem to be grossly negligent of the well-being of the staff as a considerable number

of the staff are emphatic about this lack, particularly, those involved in night shifts

and those working in the male wards. While the sister incharges also expressed

similar feelings, only 38 per cent say that there is a lack of safety and security in the

work place. It is a major challenge for the hospitals. Few hospital administrators

have indicated that there is a lack of security personnel in the hospital due to which

the lack of security will be exacerbated.

130

2.5 Hospital Policies and Rules

All hospitals under the BMC including the study hospitals have been following the

guidelines of BMC health policies. Most of the rules are the same across the

hospitals. However, certain rules are designed such that they are specifically

applicable to the peripheral hospitals of the BMC. The rules governing the hospital

should be known to the staff so that they may able to follow them properly. Also the

employees should be made to understand the implementation of the rules is uniform

and that there is no discrimination. The respondents have given their opinion in this

regard which is presented in Table 2.6.

Table 2.6 Nursing staff’s opinion on hospital rules

Opinion on Rules Yes/No Staff Nurse Sister

incharges Total

Are you aware of leave rules? No 12 (4.5) 1 (1.9) 13 (4.1)Yes 252 (95.5) 52 (98.1) 304 (95.9)

Are you satisfied with the leave rules?

No 37 (14.0) 4 (7.5) 41 (12.9)Yes 227 (86.0) 49 (92.5) 276 (87.1)

Are you aware of transfer policies?

No 35 (13.3) 3 (5.8) 38 (12.1)Yes 228 (86.7) 49 (94.2) 277 (87.9)

Are you satisfied with the transfer policies?

No 44 (18.4) 12 (23.5) 56 (19.3)Yes 195 (81.6) 39 (76.5) 234 (80.7)

Are you aware of Promotional policies?

No 40 (15.2) 1 (1.9) 41 (12.9)Yes 224 (84.8) 52 (98.1) 276 (87.1)

Are you satisfied with the promotional policies?

No 152 (57.6) 33 (62.3) 185 (58.4)Yes 112 (42.4) 20 (37.7) 132 (41.6)

Total 264 (100) 53 (100) 317 (100)(Figures in brackets indicate the percentage of nursing staff) N=317

Nearly 96 per cent of the staff are aware of the leave rules which are applicable to

them and which are followed in the hospital. Nearly 87 per cent of the staff are

satisfied with the leave rules. The nursing staff are provided with an adequate

number of leaves. They usually take leave and hence are clear on the same.

However, the need for some additional provisions with regard to leave is felt as has

been mentioned in Table 2.7. Nearly 88 per cent of the staff are aware of the transfer rules as applicable

according to the hospital they work in. Nearly 82 per cent of the staff are satisfied

with transfer rules (Table 2.6). The staff members feel that certain provisions which

are applicable to the staff with regard to transfer is dissatisfactory because it affects

their seniority. It is also opined that when the staff are transferred from the medical

131

college hospital to the peripheral hospitals, their records are not properly

transferred, there are a few incidents narrated by the staff wherein their transfer

records got misplaced by the hospital authorities. In such cases the staff have to

travel in between their duties to these hospitals to sort out the issue. It affects the

nursing staff’s morale. One of the hospital administrators confessed that the BMC

rule that any person transferred from the medical college to a peripheral hospital

shall lose their seniority is to dissuade the staff from applying for a transfer because

getting an adequate number of trained staff for medical colleges is difficult. There

are certain concerns expressed by the nursing staff with regard to transfer policies

as mentioned in Table 2.7.

As seen in table 2.6 nearly 87 per cent of the staff are aware of the promotion rules

that are applicable to them as per their hospital regulations. Nearly 42 per cent of

the staff are satisfied with the promotion rules. Promotion is considered a major

issue for the management as well for the employees. According to the employees

they expect promotions to be time bound and based on seniority or experience.

Whereas the Government expects certain formalities that need to be completed,

certain procedures and regulatory measures followed,. with regard to promotions

the staff members would like some additional provisions which have been

mentioned in Table 2.7.

Table 2.7 Suggested changes in the Hospital Rules

Leave Rules

Maternity leave should be provided for at least six months, every six months the staff should be given 10-15 days as a long holiday, leave should be sanctioned as per the staff’s needs, second and fourth Saturday should be declared a holiday, sick leave should be increased, staff should not be denied leave or forcefully asked to work when there is a shortage of staff.

Transfer Rules

Transfer of staff should be taken into consideration based on experience, staff working in BMC healthcare institutions should get transfers immediately without losing their seniority, mutual transfers should be accepted, transfer policies should be more transparent, and transfer policies should include the provision of nearest distance from home, transfer should not be linked with promotion, staff personal records particularly after transfer from one hospital to another should be kept in safe custody, administration should follow the rules as they are.

Promotion Rules

Promotion should be given based on higher education, experience, and seniority, after every 10 years of service the staff nurse should be promoted to the next level, promotion should be based on experience and performance, common test should be introduced for promotion, State and Central Governments’ rules need to be followed for promotions, promotion should be given without transfer, caste based reservation policies should not be considered for promotion.

132

2. Professional Development

A person professionally trained will be have adequate knowledge in her areas of

work. The work knowledge includes theoretical, practical, and clinical aspects. She

would apply such knowledge based on evidence or theoretical inputs. She would

able to share or communicate such knowledge to colleagues, clients and others to

bring out the best outcome. The professionally oriented person is usually open-

minded, interested in refinement of existing knowledge, striving to define patterns

of responses from patients, hospital authorities, and committed to life-long learning.

The professionals show accountability by understanding and following, ethical

standards, self-regulation and rules in practice in her work place. She shows

commitment to her patients and strives to achieve desired results and is actively

engaged in enhancing the quality of services provided. The professional staff

member exercises autonomy by independently, taking decisions, understanding the

limitations of autonomy and tackling the barriers to autonomy and seek remedy for

a particular situation. Since the nursing staff are considered to be professionals, they

posses all the said qualities. However, in the current situation the nursing staff’s

ability to align personal and organisational goals with ethical and professional

standards that include a responsibility to the patient and the community, a service

orientation, and a commitment to life-long learning and improvement have become

the major concerns. Continuous learning will lead to a better understanding of the

work process whereby the staff are able to provide patient care up to the requisite

standards. The nursing staff have expressed their opinion on the importance of

continuous training that would useful to them in Table 2.8.

Table 2.8 Nursing staff’s opinion on continuous training

How important do you think continuous

training is useful for nurses? Present designation Total Staff Nurse Sister incharges

Not Very important 4 (1.5) 3 (5.7) 7 (2.2)Not important 6 (2.3) 1 (1.9) 7 (2.2)Neither or nor important 6 (2.3) 2 (3.8) 8 (2.5)Important 118 (44.7) 14 (26.4) 132 (41.6)Very important 130 (49.2) 33 (62.3) 163 (51.4)Total 264 (100) 53 (100) 317 (100)

(Figures in brackets Percentage the number of nursing staff) N=317

133

It is expected that the nursing staff will act with bearing in mind the perspectives of

their patients, continue to learn the needs of the patients, take initiatives to enhance

the knowledge about their patients, and try to establish adequate policies for their

work areas.

Nearly 51 per cent of the staff feel that continuous learning and training is very

important for professional development also 42 per cent of the staff feel that the

training and development will be very useful to achieve greater performance at

work. Even though the nursing staff are very keen on learning and enthusiastic

about professional development there are few opportunities provided to the nursing

staff, the details of which are provided in Table 2.9.

Table 2.9 Professional development opportunities provided to the nursing staff

Sufficient opportunities provided for continued professional development by the hospital management to nursing staff

Present designation Total Staff Nurse

Sister incharges

No 113 (42.8) 11 (20.8) 124 (39.1)Yes 151 (57.2) 42 (79.2) 193 (60.9) 264 (100) 53 (100) 317 (100)

(Figures in brackets indicate the percentage of nursing staff) N=317 Nearly 39 per cent of the nursing staff expressed that they did not have an

opportunity to continue their learning in the hospital. However, when considering

the number of staff that have attended training programmes it is found that nearly

37.8 per cent have attended only one programme and 48.7 per cent have attended

two programmes. The training programmes organised by the hospitals are given

below.

2.1 Title of training programmes

The hospitals have organized few training programmes for the nursing staff and the

nursing staff attended the same during the last two to three years. The training

programmes were: management of HIV-AIDS patients, waste disposal systems and

management; bio-Medical waste management system; burns care and management;

basic computer training; breast feeding; diabetics management, pediatrics care;

cancer care management; disaster management; domestic violence; gadget

Suturing; NICU; premature management; RCH training; eye donation; ventilator

management; personality development; RNTCP; Safe delivery and stapler method.

134

It is understood that the majority of the programmes were organized in the hospitals

basically focused on infection control, communicable diseases management, and

meeting certain legal requirement and personal safety of the staff.

2.2 Employer support for training programme

Usually it is expected from the hospital management to provide necessary support

like financial support, leave with pay, sponsorship etc. for training and professional

development of the nursing staff. Most of the training programmes are organized

within the hospital or within Mumbai. Very few nurses have gone outside trainings.

The hospitals have provided support in terms of finance and leave-with-pay for the

staff.

In addition to the above, it is very important to note that the quality of training and

usefulness of the training programmes. Sometimes the same is repeated or there is

no importance given to the latest developments or an advanced course in nursing

does not make any sense to the nursing staff. It has been observed that a majority of

the past training focused on the nursing staff and patient safety related topics. Few

programmes were organised to strengthen the knowledge and the skills of the

nursing staff. Keeping this in view, a structured questionnaire was administered to

the respondents to give their areas of interest for future training programmes. The

majority of the staff expressed interest in different topics for training. The details

are given below.

2.3 Future (next 2 to 3 years) Training needs for the nursing staff

Technical Areas: Advanced nursing information technology; patient safety and

computerization; biomedical engineering; ECG reading and recording; operation

theatre techniques and management, latest technology and medicines; modern

technology and equipment handling techniques; sterilization and fumigation.

Advanced Nursing courses: Advanced nursing care techniques; BCG training;

advanced ICU nursing; breast feeding; pediatrics nursing procedures; hygiene

practices; cardiology nursing; emergency management; HIV-AIDS management;

developing creative nursing care; health malnutrition; ICCU nursing care

135

management; neurology; latest update of nursing; neonatal care; family planning;

oncology; pediatric and premature; refresher course on advance nursing; etc.

Other Areas: communication skills; motivational techniques; health education;

cleanliness; infection disease management and control; medical law and medical

legal aspects; waste disposal management; administrations and ward management;

stress management. It is found that all the above areas are very important fields

which are highly essential aspects of professional development. Keeping this in

mind, the nursing staff were requested to report on the present conditions that exist

in the hospitals enabling learning and development. The nursing staff’s responses

are presented in Table 2.10

2.4 Enabling climate for nursing professional development in the hospital

The current situation in the hospitals about the nursing professional development is

discussed as follows:

Table 2.10 Organisational Support regarding professional development

Opinion on Rules Yes/No Staff

Nurse Sister incharges

Total

Does your superior encourage your new ideas

No 65 (24.6) 15 (28.3) 80 (25.2)Yes 199 (75.4) 38 (71.7) 237 (74.8)

Have you been encouraged to develop your full potential as a nurse

No 86 (32.6) 20 (37.7) 106 (33.4)Yes 178 (67.4) 33 (62.3) 211 (66.6)

Have you been given your personal career development as high priority by superiors

No 107 (40.5) 25 (47.2) 132 (41.6)

Yes 157 (59.5) 28 (52.8) 185 (58.4)Have you been supported if applied for study leave

No 122 (46.2) 26 (49.1) 148 (46.7)Yes 142 (53.8) 27 (50.9) 169 (53.3)

(317)100 100 (317) 100 (317)(Figures in brackets indicate the percentage of nursing staff) N=317

The majority of the nursing staff (74.8 per cent) feel that their superiors encourage

their new ideas and permit their use in work related matters. Nearly 66.6 per cent of

the staff feel that the superior staff have been encouraging to develop themselves up

to their full potential as nurses. Nearly 58.4 per cent of the nursing staff feel that the

superiors give importance to the nursing staff’s personal career development.

Nearly 53 per cent of the staff feel that they get study leave for pursuing higher

136

studies if they apply for it. Further, to understand the overall climate for

professional development details are presented in Table 2.11.

Table 2.11

Enabling climate for professional development

Enabling climate

Present designation

Total Staff Nurse

Sister

incharges

Low (42.4)112 (47.2)25 (43.2)137

High (57.6)152 (52.8)28 (56.8)180

Total (100.0)264 (100.0)53 (100.0)317

(Figures in brackets indicate the percentage of nursing staff)

N=317

Overall the enabling climate for professional development is slightly better (nearly

57 per cent) in the hospital.

2.5 Performance Appraisals

Performance appraisal is not only a formal procedure to assess the performance of

the staff but also a means of providing feedback to them to improve their

performance. However, an effective performance appraisal system can be difficult

to implement, especially if front-line supervisors are responsible for large numbers

of nursing staff as is the case with the nursing supervisor. Therefore, the employees’

understanding about performance appraisal systems and how it is perceived by the

employees for professional development is important. In practice there are some

methods of performance appraisals. They are self appraisal, formal interview of the

staff by a competent team and writing confidential reports. Nearly 99 per cent of the

staff say that writing a confidential report is the only means of performance

appraisal system in their hospitals. There is no other effective performance

appraisal system in place in the hospitals. The confidential report is written by the

superior on the performance of the subordinates. This system is lacking as it

offers no scope for giving appropriate feedback to the staff so that they may

improve. The confidential report is written for every year for each nursing staff and

once in two years for sister incharges. However, of the nursing staff nearly 19 per

cent have mentioned that there was no confidential report writing as per the

137

schedule in the last six years. Many staff nurses also confirmed that there is no

effective feedback from the higher authorities that would enable the nursing staff to

improve their performance. It is observed that it is not a matter of concern to the

nursing staff or the superiors or the hospital administration because there are too

many aspects to handle.

3. Collaborative relationship and team work

A team is a collection of individuals who are interdependent in their tasks, who

share responsibilities for outcomes, who see themselves and who are seen by others

as an intake social entity embedded in one or more larger social systems, and who

manage their relationships across organisational boundaries. Work teams are

continuing work units like operation theatre, wards, critical care units and other

important areas responsible for producing goods or providing services. Work teams

are directed by superiors who make most of the decisions about what is done, how

it is done and who does it.

Healthcare services are expanding their reach in different directions due to various

aspects like specialties, research and development and other complexities. These

aspects demand more understanding, participation and interaction and cordial

relationships. It would be possible to achieve the desired output (better patient care)

only by effective interaction, collaborative relationships and effective

communication among the various professionals and non-professionals working in

the hospital. The situation is such that healthcare cannot be provided by a single

individual. In a large sized hospital several persons are a part of the patient care

delivery system. The team work and collaborative relationships complement each

other.

Team work reflects on how the people working together in an organised setup have

opportunities to participate in the team process. Similarly, the collaborative

relationship reflects the existence of good communication, faith among the

members and respect for each other. These aspects are discussed in Table 2.12.

138

Table 2.12 Working together in collaborative manner to achieve the team effectiveness

Work team relations Grading Staff Nurse Sister incharges

Total

Doctors, nursing staff, class IV employees and administrative staff work together as a team

Not at all 6 (2.3) 0 (0.0) 6 (1.9)To some extent 155 (58.7) 23 (43.4) 178 (56.2)To a large extent

103 (39.0) 30 (56.6) 133 (42.0)There is an opportunity to participate in meetings, discussions, sharing information related to nursing work

Not at all 27 (10.2) 2 (3.8) 29 (9.1)To some extent 124 (47.0) 21 (39.6) 145 (45.7)To a large extent

113 (42.8) 30 (56.6) 143 (45.1)The team members communicate freely with one another


The work load shared equally among us


Staff expertise is respected by the team members

Not at all 20 (7.6) 2 (3.8) 22 (6.9)To some extent 135 (51.1) 23 (43.4) 158 (49.8)To a large extent 109 (41.3) 28 (52.8) 137 (43.2)To a large extent 122 (46.2 ) 32 (60.4) 154 (48.6 )

Total 264 (100.0) 53 (100.0)

317 (100.0 )


A nursing staff is involved in collaborative relationships, acting as mentor, student,

coach, and support for professional growth of others as per the needs of the patients.

She is ethically informative, is good at decision making and practices values she

and her hospital subscribe to. She communicates, critically thinks and follows

ethical guidelines concerning clinical and professional practices. Only 40 per cent

of the staff nurses and 57 per cent of the sister incharges feel that they are working

together with doctors, class IV staff, and other administrative staff in an organized

manner. However, the degree of cooperativeness depends on the cases, such as

emergency, routine and non routine patient care services. It is to be noted that the

quality of healthcare services could be achieved mostly by the means of team work.

It is reported by 43 per cent of staff nurse, 57 per cent of the sister incharges and 45

per cent across both categories that there is an opportunity to participate in

meetings, discussions and sharing the information with the team regarding the

139

assignment carried out by the team. This statistic reflects that only half of the staff

is comfortable with the existing situation and there is a high scope for improving

participation through team discussions on the matters related to teamwork. Hence

there are greater opportunities for the team members to get an opportunity in

planning and executing work in their field. This shows that there is inadequate

attention focussed on the autonomy of the staff working as a team. This also has

bearing on the team members’ communication with each other. Nearly 46 per cent

of the staff nurse and 60 per cent of the sister incharges feel that they communicate

freely with one another. Regarding the other important aspects like sharing work

load it has been reported that 50 per cent of the staff nurse, 60 per cent of the sister

incharges feel that the work is distributed equally among them. Similarly, 46 per

cent of the sister incharges and 60 per cent of the sister incharges feel that their

expertise is effectively used and is respected. The nurse staff are part of the team

but they do not have adequate opportunities to participate in the team processes.

This can be understood from the Table 2.13. The overall score of the five

dimensions of team work clearly reflects that the team effectiveness marginally

high at 53 per cent.

Table 2.13

Nursing staff opinion on team effectiveness score

Collaborative Relationship for Team

Effectiveness

Present designation

Total Staff Nurse

Sister

incharges

Low (50.0)132 (33.9)18 (47.3)150

High (50.0)132 (66.0)35 (52.6)167

Total (100)264 (100)53 (100)317

(Figures in brackets indicate the Percentage of nursing staff) N=317

On a positive note nearly 66 per cent of the sister incharges say that they have many

opportunities to take decisions, as they are given opportunities at various levels and

on various occasions. Whereas the nursing staff are seen participating in their team

only at the routine team activities like work in the operation theatre, ICU, and other

some areas and not mainly at the administrative level of team management.

140

D. Respectful Relationships

Respectful relationship can be considered to be one of the needs of the staff

members. On a day-to-day basis getting adequate respect from colleagues and

coworkers facilitate effective teamwork in the hospitals. Individuals gain respect

because of their unique individual qualities apart from the job they do. If the job

provides dignity to the nursing staff and makes them feel comfortable then the staff

will really enjoy a high degree of respect. As it is understood that employees should

command respect and not demand respect, it is assumed that the nursing job is

recognised as a significant job and contribute to the process of healthcare delivery;

however, it is lacking in order to achieve appropriate status amongst the

professionals and the beneficiaries. To understand the current status of nursing staff

respectfulness, the nursing staff were asked to report their opinions on the same and

these details are presented in Table 2.14. It is reported that only one fourth of the

staff nurse and nearly 30 per cent of sister incharges feel that they are respected by

the patients and relatives. A majority of the staff, (73 per cent) feel that they do not

get respect from the patients and relatives. The nursing staff get adequate respect

from their superiors (nearly 60 per cent), colleagues and coworkers (nearly 72 per

cent), and medical staff (nearly 63 percent). It is seen that the nursing staff get most

respect from their colleagues and the least respect from patients and relatives.

Further the findings reveal that the nursing staff get a lot more respect from medical

staff then their own superiors (sister incharges, assistant matron and matron).

Comparing the sister incharges with staff nurses, the staff nurses feel that they get

lower status than their senior colleagues. The patient and their relatives treat both

categories at the same level. This is because the patients and relatives most likely do

not know the difference between these two categories, unlike the staff members in

the hospital who understand the job profiles and designations.

141

Table 2.14 Nursing staff opinion on respect they get from their patients and colleagues

Respectable relationship with stakeholders

Grading Staff Nurse Sister incharges

Total

Patient and relatives Not at all (8.3)22 (13.2)7 (9.1)29

To some extent (65.5)173 (56.6)30 (64.0)203

To a large extent (26.1)69 (30.2)16 (26.8)85Class IV and other housekeeping staff

Not at all (8.3)22 (11.3)6 (8.8)28

To some extent (59.81)58 (54.7)29 (59.0)187

To a large extent (31.8)84 (34.0)18 (32.2)102Superiors Not at all (2.3)6 (3.8)2 (2.5)8

To some extent (37.9)100 (30.2)16 (36.6)116

To a large extent (59.8)158 (66.0)35 (60.9)193Colleagues and Coworkers

Not at all (0.4)1 (1.9)1 (0.6)2

To some extent (27.3)72 (30.2)16 (27.8)88

To a large extent (72.3)191 (67.9)36 (71.6)227Medical staff Not at all (1.1)3 (1.9)1 (1.3)4

To some extent (36.4)96 (32.1)17 (35.6)113

To a large extent (62.5)165 (66.0)35 (63.1)200Total (100 )264 (100)53 (100 )317


It is culturally/commonly understood that an elderly person always get more respect

than their younger counter- parts. Table 2.15 presents the nursing staff’s opinions

on the status of respect.

Table 2.15

Respect accorded as per age: Nurses’ opinions

Age

Respectful Relationship with Nursing Staff Total

Low High

Below 30 yrs 15 (53.6) 13 (46.4) 28 (100.0)

31-35 yrs 22 (44.0) 28 (56.0) 50 (100.0)

36-40 yrs 26 (41.3) 37 (58.7) 63 (100.0)

41-45 yrs 32 (45.7) 38 (54.3) 70 (100.0)

46-50 yrs 17 (37.8) 28 (62.2) 45 (100.0)

51 & above 28 (45.9) 33 (54.1) 61 (100.0)

Total 140 (44.2) 177 (55.8) 317 (100.0)


142

It is seen that the age group of 30 to 40 years receives a high degree of respect

while the age group of 51 and above opine that they are accorded less respect than

the age group of 46- 50 years. The conclusion is that those who belong to the older

age group are not happy with the respect they get from the co-workers and other

colleagues. Similarly, it is possible to compare whether nurses with more

experience get respect in a direct proportion or not. The table 2.16 gives

information on this.

Table 2.16

Respect accorded as per experience

Years in Present Hospital

Respectful Relationship with Nursing Staff Total

Low High

Up to 5 yrs 26 (46.4) 30 (53.6) 56 (100.0)

6-10 yrs 15 (42.9) 20 (57.1) 35 (100.0)

11-15 yrs 28 (38.9) 44 (61.1) 72 (100.0)

16-20 yrs 35 (41.7) 49 (58.3) 84 (100.0)

21-25 yrs 17 (45.9) 20 (54.1) 37 (100.0)

26 & above 19 (57.6) 14 (42.4) 33 (100.0)

Total 140 (44.2) 177 (55.8) 317 (100)


It is further possible to trace the link between experience and the respect accorded

to nurses in hospitals. It is seen that from 0 years of experience to 15 years of

experience 54 per cent to 61 per cent of the staff feel that they are given a lot of

respect which is a positive trend. Whereas those with more than 16 years of

experience, that is the senior level staff, indicated a decline in the level of respect

from the hospital staff and others (58 per cent to 42 per cent). This shows that there

is a lack of cultural indoctrination in the hospitals. Moreover, either the

organisational hierarchy or the chain of command is unclear or is not followed in

the least. In such a case the senior staff seem to be unable to command respect in

the organisation and this would result in a few problems in accomplishing tasks.

There would be no control over the staff on the lower rungs across the organisation.

143

E. Supervision and Management

Nursing staff expect their superiors to engage in a positive relationship and be

caring, competent, and supportive. It is understood that most of the nursing

supervisors have learnt to apply certain skills based on their experience as a nursing

leader. Basically, the nursing supervisors are staff nurses who got a promotion and

became nursing supervisors and they have not gone through any formal training to

improve their leadership qualities.

Table 2.17 Supervisors’ support and encouragement to the nursing staff

The immediate supervisor is really


Total

Creating harassment free work environment

Not at all 34 (12.9) 9 (17.0) 43 (13.6)

To some extent 116 (43.9) 20 (37.7) 136 (42.9)

To a large extent 114 (43.2) 24 (45.3) 138 (43.5)

Motivate, and support under critical situations

Not at all 20 (7.6) 6 (11.3) 26 (8.2)

To some extent 109 (41.3) 21 (39.6) 130 (41.0)

To a large extent 135 (51.1) 26 (49.1) 161 (50.8)

Encouraging the innovative work

Not at all 31 (11.7) 3 (5.7) 34 (10.7)

To some extent 115 (43.6) 28 (52.8) 143 (45.1)

To a large extent 118 (44.7) 22 (41.5) 140 (44.2)

Helpful to solve the work and family related problems

Not at all 65 (24.6) 12 (22.6) 77 (24.3)

To some extent 98 (37.1) 20 (37.7) 118 (37.2)

To a large extent 101 (38.3) 21 (39.6) 122 (38.5)

Total 264 (100.0) 53 (100.0) 317 (100.0 )


At this stage it becomes necessary to understand that the nursing supervisors are

able to create a better environment for the staff nurses at the workplace and these

supervisors are supportive, helpful and encourage the staff to do good work etc. as

is discussed in Table 2.17.

It is a fact that employees have their own limitations in terms of knowledge,

attitude, and commitment to work. It is the responsibility of the supervisors to

understand the employees individually and as a group and extend their support

according to their subordinates’ requirements. The supervisors are the immediate

144

contact for the staff members to share their work related concerns. The supervisors

should be easily accessible to the staff members, and motivate them in case any

critical situation crops up. Table 2.18 presents certain important variables like

harassment-free work environment, motivating the staff, encouragement for

innovative work and solving their work and family related issues. It is reported that

nearly 43.5 per cent of the staff feel that their immediate supervisors create a

harassment-free work environment to a large extent. Nearly 50.8 per cent of the

staff report that they get motivated and are supported in critical situations to a large

extent. Nearly 45 per cent staff feel that their immediate supervisors encourage their

innovative work to some extent and 44 per cent of the staff state that their

immediate supervisors encourage the innovative work to a large extent. Nearly 38.5

per cent of the staff opine that their immediate supervisors are helpful to solve even

family related problems to a large extent. These are very important issues which

need to be addressed by the nursing supervisors in order to promote a good work

environment with stress-free employees.

Nursing supervisors are considered to be more task oriented. Among the four

variables, only the last variable (supervisor’s support in helping solve family and

work related problems) is considered more sensitive by both the staff nurse and the

sister incharges. The staff nurses feel there is no need to share their family related

issues with their nursing supervisors and at the same time the supervisors feel that

the nursing staff’s family issues are a private aspect and hence there is no need to

focus on these issues. However, family problems have a direct impact on the

nursing staff’s peace of mind which may affect their routine work schedule.

Table 2.18

Nursing staff’s opinion on supervisors’ support

Supervisor Support for the work

achievement


Staff Nurse Sister incharges

Low (45.5)120 (45.3)24 (45.4)144

High (54.5)144 (54.7)29 (54.6)173

(100)264 100(53) 100(317)


145

Overall, it is clearly spelt out in Table 2.18 that both the nursing staff and the sister

incharges (nearly 55 per cent) share the opinion that they get support from their

respective supervisors. However, this alone is not adequate to keep up the morale of

the staff in the work environment.

2. Opportunities to share opinion and suggestions on the work related matters

The nursing staff have various assumptions with regard to their role in decision

making since the nursing staff’s role is to carry out only the doctors’ orders and

their routine functions which has been earmarked for them. However, in a given

situation they would be able to contribute to organisations in various ways. It could

be the responsibility of the management to accommodate such provisions from time

to time through certain means like asking the staff for suggestions on various

aspects such as maintenance of hospital, quality of care, documentation process of

patient care, team work, balancing work life and family responsibilities of the

nursing staff, etc. Table 2.19 presents the five dimensions of opportunities to

participate in the decision making process.

Table 2.19 Opportunities to participate on the decision making process

Opportunities for the staff to give opinion and suggestions on


Total

Improving cleanliness, and safety of the hospital

Not at all 62 (23.5) (18.9)10 72 (22.7)To some extent 112 (42.4) (37.7)20 132 (41.6)To a large extent 90 (34.1) 23 (43.4) 113 (35.6)

Improving the quality patient care services

Not at all 67 (25.4) (28.3)15 82 (25.9)To some extent 108 (40.9) (34.0)18 126 (39.7)To a large extent 89 (33.7) 20 (37.7) 109 (34.4)

Improving the documentation, nursing work methods and processes

Not at all 82 (31.1) (32.1)17 99 (31.2)To some extent 86 (32.6) 18 (34.0) 104 (32.8)To a large extent

96 (36.4) 18 (34.0) 114 (36.0)Importance of working as a team


Methods (how to balance family and hospital requirement) for improving the work life balance

Not at all 113 (42.8) 26 (49.1) 139 (43.8)To some extent

76 (28.8) 13 (24.5) 89 (28.1)To a large extent

75 (28.4) 14 (26.4) 89 (28.1)Total 264 (100.0) 53 (100.0) 317 (100.0)


146

The management (management level just above that of the nursing staff) has to take

employees into confidence for decision making through various activities and

different methods which can help the nursing staff boost their morale. Also the

nursing staff are responsible to execute such jobs on a day-to-day basis or at least

periodically and hence involving them in the decision making process will make

them more accountable. One of the methods is taking their suggestions and opinions

for work related purposes which gives them an opportunity to participate in the

decision making process. Maintaining cleanliness is a very important aspect which

falls directly within the purview of the nursing staff. Nearly 35.6 per cent of the

staff feel that they had opportunities to give their opinion on improving cleanliness

and the safety of the hospital. As far as staff nurses are concerned nearly 34 per cent

of them feel that they have greater opportunities to participate on work related

decision making, particularly improving cleanliness, and 43 per cent of sister

incharges feel that they have greater opportunities to participate in the decision

making process of improving cleanliness.

If the hospital desires to improve the quality of care in the hospital, the most

important group which could contribute is the nursing staff because they are

instrumental in achieving better patient care. The nursing staff’s contribution in this

regard is most appreciated. Nearly 34 per cent of the staff opine that they have been

consulted to improve the quality of patient care services to a large extent. Nearly 34

per cent of the staff nurses and 38 per cent of the sister incharges were of the

opinion that their expertise was valued in this field.

Nearly 36 per cent of the staff nurse and 34 per cent of the sister incharges report

that they were consulted for improving documentation, nursing work methods and

processes to a large extent. Nursing staff are expected to do documentation in the

ward particularly with respect to admission register, discharge register, and

maintenance of case files. The practice of writing such work is done using

traditional, out-dated technologies and there is a lot of scope for improving such

practices. Nearly 25 per cent of the staff nurse and 22 per cent of the sister

incharges and 25 per cent as a group feel that they were consulted by their

supervisors or superiors about the importance of team work in the hospital. This

147

shows that team work is lacking in the hospitals as is reflected by the responses of

the nursing staff. Nearly 28 per cent of the staff nurse and 26 per cent of the sister in

charge testify that they were consulted by the supervisory staff on ways to improve

their work life balance. Work life balance involves various aspects especially

organising the nursing staff work in such a way that it does not affect the nursing

staff’s personal affairs while at the same time seeing to it that their family concerns

do not affect work related matters. It is expected some support from the

management with regard to work life balance of nursing staff however there has

been no effort in this regard.

3. Employees value on management

The employees join the organisations to achieve certain goals and satisfy some

needs within the organisation. To this end the employees expect help, support, etc.

from their organisation. They feel that the management should understand the

employees’ requirements without any pressure from the employee’s and satisfy

these needs. The employees judge the management based on the commitment

shown by the management towards satisfying the employees’ needs and

accordingly develop trust or faith in the organisation. The organisation is expected

to demonstrate fairness in the application of rules and regulations so that the

employees continue to give their best to the organisation. The nursing staff report

on the four dimensions, namely management interest in maintaining the dignity of

the patients, maintaining faith and trust of the employees, open and transparent

communication, and demonstrating that the employees are valued. The details of the

nursing staff responses on these dimensions are presented in Table 2.20

148

Table 2.20 Employees’ opinion on management

Variables Grading Staff Nurse

Sister incharges

Total

Hospital management is concerned with satisfying and up keeping dignity of patients

Not at all 41 (15.5) 5 (9.4) 46 (14.5)

To some extent 144 (54.5) 33 (62.3) 177 (55.8)

To a large extent 79 (29.9) 15 (28.3) 94 (29.7)

I have complete faith and trust on the hospital management’ s ability on justice )equity/ fairness to all

Not at all 81 (30.7) 8 (15.1) 89 (28.1)

To some extent 89 (33.7) 23 (43.4) 112 (35.3)

To a large extent 94 (35.6) 22 (41.5) 116 (36.6)

The hospital management maintains transferant and open communication on sharing information to all

Not at all 62 (23.5) 9 (17.0) 71 (22.4)

To some extent 115 (43.6) 24 (45.3) 39 (43.81)

To a large extent 87 (33.0) 20 (37.7) 107 (33.8)

I could see the hospital makes sure that the employees are valued

Not at all 52 (19.7) 7 (13.2) 59 (18.6)

To some extent 123 (46.6) 27 (50.9) 150 (47.3)

To a large extent 89 (33.7) 19 (35.8) 108 (34.1)

Total 264 (100.0 )

53 (100 ) 317 (100 )


The nursing staff give more value to the hospital management when the hospital

management treats its patients with dignity and aims to give them full satisfaction.

The nursing staff are engaged indirect patient care as per the policies of the hospital

management. In this regard, nearly 30 per cent of the nursing staff feel that the

hospital management is concerned with satisfying and maintaining the dignity of

the patients to a large extent. This indicates to the hospital management that there is

still a very large scope to improve the situation. Only 37 per cent of the nursing

staff feel that they have complete faith and trust in the hospital management’s

ability for justice (equity or fairness) accorded to all staff. This demonstrates that

the management needs to improve its record of taking employees into confidence

on issues concerning management affairs. This situation has to be considered

seriously. Nearly 34 per cent of the nursing staff feel that hospitals ensure open and

transparent communication of its affairs and share the information with all

concerned. However, this is not adequate because a large per cent of the staff feel

that the hospitals rarely pay attention to this aspect. Finally, nearly 34 per cent of

149

the staff feel that they feel that the hospital ensures that the employees know that

they are valued to a large extent but the major part of the respondents are not happy

with the management’s practices in this regard. It shows that the hospital

management lacks consideration for its employees who are the cogs in the wheel of

the organisation. Overall, the employee’s opinion about the management is not very

satisfactory. The employees face many problems which can be easily handled by

the hospital without much difficulty but the hospital management prolongs looking

into such problems and do not try solve it at once.

F. Service Quality and Patient Safety

The quality of patient care is the main concern for the patients as well as for the

hospitals. The quality of care depends on various important factors like quality of

resources, organizational processes, and methods of delivery. The nursing staff are

concerned with the quality of patient care and the safety of the patients. Another

key aspect in the hospital is patient safety. Patient safety includes physical safety,

reduction of medical errors, and appropriate safety culture. Table 2.21 provides

information on the three dimensions of quality of patient care and patient safety as

is reported on by the nursing staff.

Table 2.21 Opinion on nursing quality care and patient safety

Opinion on nursing quality care and patient safety


Total

Every nurse has the opportunity to perform the types of work at their level best

Strongly disagree 17 (6.4) 2 (3.8) 19 (6.0)Disagree 57 (21.6) 10 (18.9) 67 (21.1)Agree 144 (54.5) 32 (60.4) 176 (55.5)Strongly agree 46 (17.4) 9 (17.0) 55 (17.4)

The overall quality of nursing care provided is high


The hospital has provided enough facilities for protection of patients in the ward


Total 264 (100.0) 53 (100.0)

317 (100.0 )


150

Nearly 72.4 per cent (agree 55.5 per cent + strongly agree 17.4 per cent) agree that

every nurse has the opportunity to perform various types of work at their level best.

It is to be noted that the nursing staff do not have many opportunities in terms of

decision making and participation in other important aspects but they do have

multiple opportunities to work in different areas of healthcare like ICU, OT, special

wards etc. which gives them a variety of experience due to the popular practice of

job rotation. Nearly 65per cent (agree 47 per cent + strongly agree 18 per cent)

agree that the overall quality of nursing care is high in the hospital. However, nearly

35 per cent of the nursing staff are unable to agree on the existence of high quality

of care in the hospital due to various reasons which include lack of material

availability, shortage of staff, lack of professional training and development in the

hospital. Only 51 per cent (agree 41 per cent + strongly agree 10 per cent) agree that

the hospital has provided enough facilities for protection of the patients in the

wards. On the other hand, nearly that many (49 per cent) disagree with the notion

that the hospital has provided enough facilities for the protection of the patients in

the wards. There is a lack of patient safety measures in the hospital. Also there is no

strong mechanism for bring patient safety culture in effect in the hospitals. This

reflects the organisation’s beliefs in the traditional practices of patient care delivery

and its inability to cope with the changes in the healthcare delivery models and the

modern patient’s requirements.

151

PART-3 QUALITY OF WORK LIFE INDICATORS

The third Part of the chapter 4 is organized based the analysis and findings and

details are as follows: Part 3 Overview of quality of work life Indicators” and has

seven major sections such as work life balance.

A. Work life Balance

It is commonly understood that nursing is a job that is mostly suitable for women as

it provides them greater opportunities. Due to an increase in educational

achievements by women, decreased family size, stagnant or declining wages for

men or unemployment of spouses, increased cost of maintaining a middle-class life

style, lengthening life span, and liberalization of attitudes concerning women's and

men's proper roles within the family structure an increasing number of women have

taken up nursing as a profession. In contrast, there is negligible agreement about

women's ability to function equally well in the two demanding arenas of work and

family. Men's ability to succeed at the same balancing feat has been taken for

granted because, historically, successful fulfillment of the worker role was

synonymous with successful fulfillment of the husband/father role. In practice, by

focusing heavily on women, work-family research had reflected the assumption that

work-family issues are solely women's issues – an assumption increasingly called

into question. In a given situation, the nursing staff have to handle both the family

and work. It is perceived that there is some difficulty in maintaining the family

without compromising on the work front or vice versa. Table 3.1 presents certain

key dimensions of balancing work and family by focussing on issues such as work

schedule, personal relationships, children’s education and well being, family and

personal engagements, travelling to and from the work place, and enjoying the work

place.

152

Table 3.1

Nursing staff opinion on work and life balancing issues

Nursing staff ability to make balance between

the work and family Grading Staff

Nurse Sister

incharges Total

My work schedule affects my family and personal relationships at home

Not at all 84 (31.8) 10 (18.9) 94 (29.7)

To some extent 25 (47.31) 28 (52.8) 53 (48.31)

To a large extent 55 (20.8) 15 (28.3) 70 (22.1)

My working life has greater impact on my children’s education, paying attention and their well being

Not at all 95 (36.0) 14 (26.4) 109 (34.4)

To some extent 109 (41.3) 26 (49.1) 135 (42.6)

To a large extent 60 (22.7) 13 (24.5) 73 (23.0)

I have enough time for my family, friends and other personal engagements

Not at all 47 (17.8) 15 (28.3) 62 (19.6)

To some extent 134 (50.8) 26 (49.1) 160 (50.5)

To a large extent 83 (31.4) 12 (22.6) 95 (30.0)

Journey between the workplace and home is hectic

Not at all 87 (33.0) 20 (37.7) 107 (33.8)

To some extent 103 (39.0) 23 (43.4) 126 (39.7)

To a large extent 74 (28.0) 10 (18.9) 84 (26.5)

Balancing between the work and family becomes difficult now

Not at all 75 (28.4) 12 (22.6) 87 (27.4)

To some extent 128 (48.5) 30 (56.6) 158 (49.8)

To a large extent 61 (23.1) 11 (20.8) 72 (22.7)

I am really enjoying the current work

Not at all 19 (7.2) 2 (3.8) 21 (6.6)

To some extent 126 (47.7) 22 (41.5) 148 (46.7)

To a large extent 119 (45.1) 29 (54.7) 148 (46.7)

Total 264 (100 ) 53 (100) (100)317(Figures in brackets indicate the percentage of nursing staff) N=317

Personal relationships form the basic foundation of a family. As an important

member of the family, the nursing staff member has to maintain strong relationships

with her spouse, children and the elders at home. As indicated in Table 3.1 nearly

70 per cent (some extent 48 per cent and large extent 22 per cent) of the nursing

staff have reported that the current work schedule of the hospital affects their

personal relationships. Since nursing involves a shift system and a hectic work load

which exhausts most of their time and energy.

153

Table 3.1 depicts that nearly 23 per cent of the nursing staff feel that their working

life has a greater impact on their children’s education and their well being than on

the other family members. It is to be noted that the respondents being ladies have

dynamically involved in family relationships and take more responsibility for their

children, especially the younger ones. On the other hand, nearly 34 per cent of the

staff report that their work life does not come in the way of managing their

children’s education. However, 66 per cent (not at all 43 per cent and to some

extent 23 per cent) of the nursing staff indicated that their working life had affected

their children education, and their well being. It means they are unable to pay

attention to their children’ education and their well being. Among the respondents,

the married women face more challenges than the unmarried women. The various

issues associated with married women are social issues, family issues and work

related matters. It is expected that the nursing staff have the ability to handle both

areas, that is work and home and maintain the balance between these two. It should

be noted that among the married women 34 per cent have indicated that the working

life has a greater impact on their children’s education and their well being which

has been presented in table3.2.

Table3.2

The working life impact on the married nursing staff

Current marital status:

My working life has greater impact on my children's education, paying attention and their

well being Total

Not at all To a some

extent To the large

extent

Unmarried 19 (100) 0 (0) 0 (0) 19 (100)

Married 100 (34.2) 126 (43.2) 66 (22.6) 292 (100)

Widowed 1 (20.0) 3 (60.0) 1 (20.0) 5 (100)

Divorced 1 (100) 0 (0) 0 (0) 1 (100)

Total 121 (38.2) 129 (40.7) 67 (21.1) 317 (100)

(Figures in brackets indicate the percentage of nursing staff) N=317, X2 =35.2, P=0.000

As is seen in Table 3.1, nearly 30 per cent of the nursing staff feel that they have

enough time for family, friends and other personal engagements. Nearly 70 per cent

(some extent 50 per cent and not at all 20 per cent) have indicated that there is no

154

scope for them to socialise. Socialisation is an important need of the nursing staff.

Most of nursing staff hail from Maharashtra while some of the staff are from

different states. Since a majority of the nurses have family ties in local areas they

are keen to attend family functions, festivals, personal engagements and so on. On

the other hand, the other staff nurses need to visit their home towns. Since a

considerable number of respondents indicated that they are unable to have adequate

time for the said purposes it is clear that organisational polices, hospital

management practices and other institutional difficulties like staff shortages are

major issues that need to be focussed upon.

It is seen in Table 3.1 nearly 66 per cent (some extent 40 percent plus large extent

26 percent) of the nursing staff feel that the journey between their workplace and

home is hectic to a large extent. Even though the nursing staff travel on a daily basis

to their workplace there are times when travel becomes very irritating due to

overcrowding in trains and buses, insufficient travel facilities and different shift

timings. This causes unnecessary tension may reflect in reduced effectiveness of the

staff at work and home.

As per table 3.1 nearly 73 per cent (some extent 40 percent plus large extent 23

percent) of the nursing staff feel that balancing work and family has become

difficult in modern times. However, 27 per cent of the staff feel that balancing

between the work and family is not at all difficult these days. Individuals work to

make life is comfortable but when work life becomes difficult it leads to adverse

consequences for the nursing staff’s health, managing the family and patient care.

Table 3.1 indicates that nearly 47 per cent of the staff feel that they are really

enjoying their current work to a large extent. Even though many factors have been

associated with balancing work with family, among all these factors work

enjoyment is considered a very important factor. This aspect is to some extent in

line with the motivational potential score. Work enjoyment is the major indicator

for work life balance. The analysis of the responses leads to the conclusion that only

47 per cent of the nursing staff have are able to balance their work life with their

family life.

155

Nursing staff preference and commitment to the work

The nursing staff were asked to list their preference if the situation demands them

to be present at the workplace while their presence is also required elsewhere such

as attending an important family function or an emergency at the hospital. The

nursing staff’s responses have been presented in Table 3.3.

Table 3.3

Nursing staff’s preferences and commitment to their work The nursing staff required to attend important family function or emergency at the hospital –what would be their preferences.

Present designation


Not sure 86 (32.6) 19 (35.8) 105 (33.1)Preference to work 125 (47.3) 27 (50.9) 152 (47.9)Preference to family 53 (20.1) 7 (13.2) 60 (18.9)Total 264 (100) 53 (100) 317 (100)


As shown in Table 3.3 nearly 48 per cent of the staff give preference to work when

the situation demands that they are required to be at the work place as well

elsewhere such as their home. Nursing staff are attached to their work. It shows

that they are very committed to their work. It is to be noted that when the nursing

staff carry out their work whole heartedly on most occasions. Since the nursing staff

are highly dedicated to their profession, they naturally give more preference to their

work. However, nearly 33 per cent of the staff are unable decide on this matter

which clearly indicates that there are variations among the nurses and reflects the

changing attitudes towards the nursing profession. In these cases there is a kind of

mixed opinion among the nurses about commitment to their work.

B. Absenteeism

Absenteeism is one of the major issues in the hospital. Staff members being absent

from work causes various problems to the hospital which include work pressure for

existing staff, creating temporary shortage of the workforce, patients getting

affected to a large extent at the same time certain specific jobs handled by select

individuals that cannot be accomplished until the person responsible returns to

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work. In the study hospitals absenteeism is one of the issues that are a primary

concern. The nursing administrators face many difficulties managing the nursing

staff’s absenteeism that is presented in Table 3.4. This table indicates the number of

days that staff members were absent in the course of last one year.

Table 3.4

Number of days nursing staff have remain absent for the work during the year

Absenteeism number of days recoded



No absenteeism 17 (6.4) 2 (3.8) 19 (6.0)1-20 days 138 (52.3) 26 (49.1) 164 (51.7)21-40 days 95 (36.0) 22 (41.5) 117 (36.9)41-60 days 10 (3.8) 2 (3.8) 12 (3.8)61 & above days 4 (1.5) 1 (1.9) 5 (1.6)Total 264 (100) 53 (100) 317 (100)


It is important to note that almost 94 per cent of the staff absented themselves from

work on one or the other occasion during the year and only 6 per cent had never

been absent during the year. Nearly 51 per cent of staff remained absent for 1-20

days in a year and 37 per cent for 21-40 days in a year. The mean number of days

for absenteeism is 22 days in a year and the standard deviation is 12.9. It means 94

per cent of the staff are not available 22 days in a year. The hospital has a policy

whereby the nursing staff can take leave 11 days earned leave at a time and for a

maximum of three times a year. This condition forces the nursing staff to restrict

their vacation to a short duration. Furthermore, the nurses face many problems is

getting their leave sanctioned the second or third time in the same year unless they

have strong justifications for their request. On the other hand, the hospital already

faces an acute shortage of the nursing workforce, hence it is impossible to sanction

more days off work for the nursing staff. Even some of the staff mentioned that the

in being permitted to ustilise their casual leave is due to the shortage of staff. This

shows that the hospital management tries to manage the situation by using the

existing workforces by compromising the leave benefits of the staff.

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Some of the major reasons stated by the nursing staff for taking leave as mentioned

by the staff are family and personal reasons, heath related reasons, attending

functions, etc. These details are presented in Table 3.5.

Table 3.5 Reasons for nursing staff absenteeism

What were the reasons for such absenteeism? Present designation

Total Staff Nurse

Sister incharges

Personal and family reasons (54.3)134 (52.9)27 (54.0)161

Health related problems of self and family members (19.8)49 (11.8)6 (18.5)55

Social reasons like attending functions, festivals and others (6.5)16 (9.8)5 (7.0)21

Work related tension, tardiness, work stress and others (3.6)9 (2.0)1 (3.4)10

Don't feel like to attend the work due to lack of support (3.6)9 (9.8)5 (4.7)14

Leave travel concession (8.1)20 (11.8)6 (8.7)26

Children’s education (4.0)10 (2.0)1 (3.7)11

Total (100)247 (100)51 (100)298(Figures in brackets indicate the percentage of nursing staff) N=298

One of the major reasons for absenteeism among the respondents is personal and

family reasons. Nearly 54 per cent of the staff were absent for duty for personal and

family reasons. Nearly 18.5 per cent have reported that health issues concerning

themselves and their family members. There is a noticeable difference between the

staff nurses and the sister incharges concerning health related issues as reasons for

absenteeism. The sister incharges resorted to this reason only 12 per cent of the time

whereas the staff nurses used up this reason 20 per cent of the time. The reason for

this variation could be that the staff nurse generally have more responsibilities in

terms of taking care of their own and their family members’ health. Nearly 7 per

cent of the staff had taken leave for social reasons like attending functions, festivals

and others. In this case the nursing staff have already reported that there is little

scope for getting time off for the same. Nearly 9 per cent of the staff used their

leave to travel during their vacation. . Other than these reasons the nursing staff also

remained absent for like work related tension, tardiness, work stress , not wanting to

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attend work on a particular day, children’s education, etc. that though amount to a

marginal percentage, however, it is an issue for the hospital to look into There are

situations when the nursing staff have to work despite their own illness or some

such reason. They do not have any way to avoid work or remain absent in such

situations. The details are presented in Table 3.6.

Table 3.6 Presenteeism among the nursing staff

During the last year, how many days did you work despite an illness or injury because you felt you had to?



No 171 (64.8) 30 (56.6) 201 (63.4)Yes 93 (35.2) 23 (43.4) 116 (36.6)Total 264 (100) 53 (100) 317 (100)


Nearly 37 per cent of the staff have worked in the hospital despite illness or injury

in the hospital. It happens in any organisation because the staff members’ presence

is essential in such situations. The presenteeism is higher among the sister incharges

as compared to that of the staff nurses that is the staff nurses have reported 35 per

cent whereas the sister incharges have reported 43 per cent who attend the work

despite an illness or any other personal reason. The nursing staff show

presenteeism certain reasons are explained in Table 3.7.

Table 3.7 Reasons for Presenteeism

Reasons for Presenteeism Present designation


Not applicable 171 (64.8) 30 (56.6) 201 (63.4)Double day salary deduction 3 (1.1) 0 (0.0) 3 (0.9)

Due to own commitment to the work 3 (1.1) 1 (1.9) 4 (1.3)

Attending work due to emergency 8 (3.0) 4 (7.5) 12 (3.8)

Feel better after attending the work 4 (1.5) 2 (3.8) 6 (1.9)

I would like to work even I am an sick 3 (1.1) 2 (3.8) 5 (1.6)

Refusal to grant leave by administration 7 (2.7) 1 (1.9) 8 (2.5)

Shortage of nursing staff in the hospital 59 (22.3) 12 (22.6) 71 (22.4)

To save my casual leave 6 (2.3) 1 (1.9) 7 (2.2)

Total 264 (100) 53 (100) 317 (100)


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With reference to Table 3.7 the staff members have worked in the hospital in spite

of their illness or injury for a number of reasons like the administration may deduct

their salary, to avoid absenteeism, because there is a huge shortage of staff, the

authorities have refused to sanction leave, there is compulsory duty and fear of

deduction of double-day salary, in response to a disaster, due to their work

commitment, for emergency work, feeling better when on duty, feeling responsible

to the department, interested in work responsibility, already used up all the leaves,

interested in patient care, since the staff stay in quarters nursing administration calls

them to replace the absentee, to save their own casual leaves.

C. Work Stress

Nursing staff have the possibility of getting into stressful situations in the hospital.

The sources of stress may be moral factors when people are prevented from doing

‘good’ they may feel that they have not done what they ought to have or that they

have erred, thus giving rise to a troubled conscience. The nursing staff usually play

two roles, as professionals and as moral actors. In a situation the nursing staff’s

inability to function according to their conscience is associated with several

phenomena: a decreased well-being in nurses, shortages of nurses, burnout, and

distancing from patients. These negative consequences of a troubled conscience

make it imperative to understand more about situations that evoke it, in order to

help guide the personnel on how to relate to professional values and rules and their

personal conscience. There are various factors associated with nursing work stress

are external influences as well internal factors which are discussed in Table 3.8. The

nursing staff’s work stress consists of 11 dimensions as stated below.

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Table 3.8 Factors contribute nursing staff work stress

Were you stressed by the following aspects

Yes/No Staff Nurse Sister incharges

Total

Forced to provide care that you feel wrong

No 71 (26.9) 17 (32.1) 88 (27.8)

Yes 193 (73.1) 36 (67.9) 229 (72.2)

Wrong medication by yourself No 96 (36.4) 28 (52.8) 124 (39.1)

Yes 168 (63.6) 25 (47.2) 193 (60.9)

Sometimes disagree with the care/medicines prescribed by a doctor

No 79 (29.9) 22 (41.5) 101 (31.9)

Yes 185 (70.1) 31 (58.5) 216 (68.1)

Seeing patients being insulted by others

No 45 (17.0) 11 (20.8) 56 (17.7)

Yes 219 (83.0) 42 (79.2) 261 (82.3)

Seeing patients being injured/falls/bedsore

No 59 (22.3) 16 (30.2) 75 (23.7)

Yes 205 (77.7) 37 (69.8) 242 (76.3)

Find yourself avoiding patients or family members who need help or support due to your work pressure

No 145 (54.9) 27 (50.9) 172 (54.3)

Yes 119 (45.1) 26 (49.1) 145 (45.7)

My family issues take more energy than the official work however I would like to devote myself to the work

No 158 (59.8) 29 (54.7) 187 (59.0)

Yes 106 (40.2) 24 (45.3) 130 (41.0)

I feel that I am unable to live up to others’ expectations of my work

No 134 (50.8) 34 (64.2) 18 (53.0)

Yes 130 (49.2) 19 (35.8) 19 (47.0)

The situations makes me lower my aspirations to provide good care

No 128 (48.5) 32 (60.4) 160 (50.5)

Yes 136 (51.5) 21 (39.6) 157 (49.5)

When I am badly treated No 70 (26.5) 16 (30.2) 86 (27.1)

Yes 194 (73.5) 37 (69.8) 231 (72.9)

My workload makes me to feel sick No 98 (37.1) 21 (39.6) 119 (37.5)

Yes 166 (62.9) 32 (60.4) 198 (62.5)


Table 3.8 indicates that nearly 72 per cent of the staff feel that they are disturbed or

stressed when they are forced to provide care that they instinctively or through

experience feel is wrong. It is the situation in which the nursing staff have to

manage the patients which adds to the pressures on the nursing staff in the

workplace. If the pressure exceeds the nursing staff’s ability to handle them, the

staff member’s frustration levels increase to an extent that it affects their

professionalism. Nearly 60.9 per cent of the staff feel that they get stressed when

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they give wrong medication to the patients. Giving wrong medicine usually does

not happen, however, there are many other factors that need the attention of the

nursing staff which does create a window for error in treating the patients. This

results in burnout for the nursing staff. Nearly 68 per cent of the staff feel that they

get stressed when they disagree with the care or medicines prescribed by the doctor.

Even though providing prescriptions are not the concern of the nursing staff but the

staff get become involved on moral grounds because the nursing staff play a vital

role in patient care management. Such situations may disturb the nursing ability to

function effectively.

Table 3.8 shows that nearly 82 per cent of the nursing staff feel that they get

stressed when they see their patient being insulted by anyone in the hospital. This

indicates that the nursing staff have a high degree of accountability and feel concern

for their patients. This create moral issues and dilemmas in the nursing staff’s

minds. Nearly 76 per cent of the staff feel stressed when they see the patient get

injured or fall from the beds or get bedsores. As a professional they would like to

provide better patient care to avoid such incidences. If the situation is such that they

are unable to provide the very best care the staff become stressed. This is a

professional issue that needs to be tackled.

Table 3.8 indicates that nearly 46 per cent of the staff are disturbed when they find

themselves avoiding patients or family members who need help or support due to

their work pressure. Since the nursing staff play multiple role as professionals, they

experience task pressure (number of task to be performed at a time) and being an

active member of their own family they experience time pressures which make

them compromise when providing service to the patients or taking care of the

family members which affects the nursing staff.

Table 3.8 indicates that nearly 41 per cent of staff feel that they are stressed out due

to their family issues and that these problems tax their energy more than the official

work, however, they would like to devote themselves to their work. More

specifically, if the nursing staff give more time to their family, they feel guilty. This

leads to ethical or moral dilemmas which affect the nursing staff’s routines. Nearly

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50 per cent of the staff feel that they are suffer stress when they are unable to live

up to others’ expectations in their work front. People usually hope for a positive

opinion from others. If the nursing staff is unable to satisfy their patients’

expectations they feel dissatisfied with themselves on moral and ethical grounds.

Nearly 73 per cent of the nursing staff feel that they get stressed when they are

badly treated. Nursing is considered to be a noble profession and hence people

providing such services should be treated well by patients as well as the

management. If there is a situation when they are not given importance they feel

bad. Nearly 62.5 per cent of the staff feel that their work load makes them feel sick

which in turn adds to their stress. Work load is one of the major contributors to the

nursing staff’s stress. The nursing staff’s workload is the most frequently reported

stressor. Work overload in combination with inadequate resources (such as lack of

time and inadequate staffing) seems to be the greatest source of stress in health care.

A heavy workload typically entails not being able to perform duties to the nurse’s

own satisfaction.

When nurses are unable to fulfill the moral goals of nursing namely, to protect

patients from harm and to provide good care they experience moral distress.

Impediments to fulfilling these moral goals may be shortage of staff, inadequately

trained staff, or organizational constraints. Inability to act according to one’s values

leads to moral distress.

D. Communication

“Nurses must be as proficient in communication skills as they are in clinical skills.”

Clinical knowledge, skills, and judgment are not enough to achieve excellent

outcomes. Nurses must demonstrate the ability to be communicators in all aspects

of their professional work in order to achieve safe care and quality outcomes. The

nursing staff should have good communication skills be able to focus on finding

solutions, achieve desirable outcomes, seek to protect and advance collaborative

relationships among colleagues; invite and hear all relevant perspectives; develop

goodwill and mutual respect to build consensus and arrive at a common

understanding; demonstrate congruence between words and actions, and hold others

accountable for doing the same. Further, the nursing staff should have access to

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understand and use communication technologies, be able to communicate clearly

about clinical, financial, and work environment outcomes and showcase high

performance on the professional front. To understand the nursing staff’s

communication status in the hospital there are eight dimensions that are used. The

details are explained in Table 3.9.

Table 3.9

Nursing staff communication

Variables Yes/No Staff Nurse Sister incharges Total

I could openly communicate on the mistakes which I committed

No 42 (15.9) 3 (5.7) 45 (14.2)

Yes 222 (84.1) 50 (94.3) 272 (85.8)

My superiors encouraged me to report the near- miss faults

No 104 (39.4) 13 (24.5) 117 (36.9)

Yes 160 (60.6) 40 (75.5) 200 (63.1)

My superiors use abusive language

No 192 (72.7) 43 (81.1) 235 (74.1)

Yes 72 (27.3) 10 (18.9) 82 (25.9)

My superiors never let me down in front of others.

No 184 (69.7) 40 (75.5) 224 (70.7)

Yes 80 (30.3) 13 (24.5) 93 (29.3)

The majority of my normal, daily activities on the job are guided by the written operating instructions

No 232 (87.9) 49 (92.5) 281 (88.6)

Yes 32 (12.1) 4 (7.5) 36 (11.4)

I get communication about latest technologies which are part of my routine work

No 210 (79.5) 42 (79.2) 252 (79.5)

Yes 54 (20.5) 11 (20.8) 65 (20.5)

I have difficulty in communicating with different patients who speak and understand different languages (language barrier)

No 64 (24.2) 13 (24.5) 77 (24.3)

Yes 200 (75.8) 40 (75.5) 240 (75.7)

Lack of availability of information in time

No 143 (54.2) 33 (62.3) 176 (55.5)

Yes 121 (45.8) 20 (37.7) 141 (44.5)


There are some important dimensions of communications are discussed as follows;

the nursing staff have scope for making mistakes which may arise due to difficulty

in following directions, demonstrating poor clinical judgment, or inadequate

assessment of patients. Table 3.9 depicts that nearly 85 per cent of the nursing staff

reported that they could openly communicate about their mistakes they commit

during the work. Similarly, nearly 63 per cent of the staff feel that their superiors

encouraged them to report the near-miss mistakes or faults. This shows that the

superiors are open minded and accept the nursing staff’s mistakes and hence there is

164

scope for the nursing staff to get feedback from their superiors and improve their

clinical skills. Further, it strengthens the nursing staff’s ability to effectively triage

patients or set priority when caring for patients, identifying the critical symptoms or

test results, attempting to manage difficult situations with appropriate skill level or

competency.

Nearly 30 per cent of the staff feel that their superiors use abusive language. When

there is foul language used by the superiors when addressing their staff by and they

are condescending, rude, abrupt, insulting, aggressive and angry. Dismissive

behaviour such as telling others to shut up or not caring for what others think,

dismissive remarks about another’s role in the team, educational qualifications, or

lack of experience all have negative consequences on the nursing spirit; however,

nearly 70 per cent of the staff reported that their superior have never used abusive

language. This shows that there are a few exceptions among the superiors while the

majority is good in communicating with the staff. This can help the nursing staff

continue to maintain their spirit and motivation.

Nearly 29 per cent of the nursing staff reported that their superiors have let them

down in front of others. This shows that there is a lack of support that the nursing

staff receive from their superiors which include: unhelpful behaviours, refusing to

answer a question or providing needed patient information, impatience and making

it difficult for others to ask for assistance, complaining when asked to help or

refusal to assist others, or unhelpful critique of others. However, nearly 71 per cent

of the staff feel that their superiors never let them down in front of others in any

kind of situation. It shows that the majority of superior nursing staff have learnt the

art of communicating properly and uplifting the nursing staff’s spirits. This is also a

very important indicator that there is considerably good nursing leadership that

exists in the hospital.

The nursing staff should be guided with certain standard operating protocols so that

the staff can work without any difficulty. In the absence of superior staff or guides

the staff can function without any difficulty with the help of written rules. Nearly

86.4per cent of the staff reported that that their normal, daily activities on the job

165

are not guided by written operating instructions in the hospital. However, 20.5 per

cent feel there are some written rules which are available to guide them. This shows

that the staff members need regulations to be formally communicated to them to

prevent practice of any kind of regress procedure. It may lead to patients being

harmed. In the absence of standard procedure there is no way to understand a failure

and take the corrective steps. Even at this stage there is no verification or

confirmation by the superiors on the work carried out by the staff nurses.

Nearly 78 per cent of the staff feel that they are not informed about the latest

technologies which could impact their routine work. This shows that the nursing

staff do not have updates which would then result in incompetence. As a result, the

nursing work might include questionable interventions, inability to deliver a

standard of care, lack of critical thinking skills, or lack of knowledge and skills

required by one's position.. The senior doctors believe that the nursing staff should

only carry out the work which they have been told to do and therefore there is no

scope for the nursing staff to use their own ideas or the knowledge they possess.

Nearly 76 per cent of the staff feel that they have no difficulty in communicating to

different patients who speak and understand different languages (language barrier).

This shows that the nursing staff have knowledge of the various languages used in

Mumbai. Language barrier is an extremely important aspect for any individual. If a

person cannot speak well in a particular language when a majority are using, it

would be very difficult for the persons to deal with patients. However, 24 per cent

of the staff feel that they do have language difficulties when the patient speaks

something other than the locally used languages. At present the hospital

administration follows the rule that every nursing staff should be able to speak,

read, write as well clear a exam conducted by the Corporation. If any staff member

fails to pass that examination they will be penalised by having their increment

stopped. This provision is followed in the hospitals to ensure that the nursing staff

are helpful to the patients particularly as effective communicators because

communication plays a vital role in the patient care process.

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Nearly 55.5 per cent of the staff feel that there is a lack of availability of

information and this results in a time lag for taking some decision or doing some

work. This shows that the nursing staff needs to wait for information for various

purposes including admission, medication, treatment procedures, discharge, and

other administrative issues. This also affects the teamwork of nursing staff, as non-

cooperative nurses may hinder the communication flow, not valuing or

acknowledging the contributions of others, unhealthy competition with others, not

being dependable, or looking good at other's expense. Timely information is

extremely important for proper patient care in the hospitals and the administration

should facilitate its smooth flow

E. Job Satisfaction

Job satisfaction is another important issue for professionals. Job satisfaction has a

number of facets such as satisfaction with: work, pay, supervision, quality of work

life, participation opportunities, organisational commitment, and organisational

climate. There are a number of factors associated with the measurement of job

satisfaction of the nursing staff, however, only a few dimensions have been used to

understand the job satisfaction of nursing staff in the study hospitals. The

dimensions are: satisfaction with the present job, employer value on the nursing

work, overall satisfaction of choice of nursing as a career and encouraging others to

become a nurse. The details are presented in Table 3.10.

37 per cent of the nursing staff have reported that the present job gives them

complete satisfaction. It is over one third of the respondents. However, 44 per cent

of the staff report that they are satisfied with the current job to some extent only.

Rather a large percentage (19 percent) report complete dissatisfaction. Hence it can

be said 44 percent plus 19 percents (63 percent) are some extent or totally

dissatisfied. This response does not give complete satisfaction and hence a large per

cent of the staff are not satisfied with their current position. Nearly 32 per cent of

the staff feel that their employer places a high value on the work they do. The other

49 per cent indicate that this is true to some extent. These responses indicate that

nurses do not find a strong value accorded to them.

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Table 3.10 Nursing staff job satisfaction

Variables Grading Staff Nurse

Sister incharges

Total

The present job gives me complete satisfaction

To a large extent 96 (36.4) 22 (41.5) 118 (37.2)

To some extent 123 (46.6) 16 (30.2) 139 (43.8)

Not at all 45 (17.0) 15 (28.3) 60 (18.9)

My employer places a high value on the work I do

To a large extent 82 (31.1) 19 (35.8) 101 (31.9)

To some extent 140 (53.0) 16 (30.2) 156 (49.2)

Not at all 42 (15.9) 18 (34.0) 60 (18.9)

Overall, I am satisfied with my choice of nursing as a career

To a large extent 127 (48.1) 24 (45.3) 151 (47.6)

To some extent 75 (28.4) 11 (20.8) 86 (27.1)

Not at all 62 (23.5) 18 (34.0) 80 (25.2)

I would encourage others to become a nurse

To a large extent 133 (50.4) 32 (60.4) 165 (52.1)

To some extent 41 (15.5) 6 (11.3) 47 (14.8)

Not at all 90 (34.1) 15 (28.3) 105 (33.1)

Total 264 (100.0) 53 (100.0) 317 (100.0 )


The majority of the nursing staff feel that their employers do not give much

importance to the work they do. Nearly 48 per cent of the staff feel that overall they

are satisfied with their choice of nursing as a career. On the other hand, a

considerable number of the staff (25 per cent) regret that their choice of nursing as a

career. There are a number of reasons for such a response. The nursing staff

compare the modern nursing profession with the practices of the olden days. In

earlier days (15-20 years ago) the nursing job was respected by the patients, the

nursing staff were fully committed to the job, material supply was adequate, etc.

But these days the situation is very different which is not favourable. Only 52 per

cent of the nursing staff have reported that they would recommend others to become

a nurse as well. More than one third do not recommend it at all. This shows that the

existing nursing staff particularly the respondents are not in favour of youngsters to

choose nursing as a profession. The nursing staff indicate that the reasons for the

168

same are that the nursing job is plagued by a number of problems like continuous

duty, night shifts, lack of facilities, lack of management support, etc.

F. Organisational Culture and Climate

Culture is a set of norms and expectations that guide the organisation as a whole.

The organisational culture and climate should be favourable to the nursing staff for

effective functioning and patient care delivery. The organisational culture and

climate consists of various elements which are qualitative in nature. Of course, the

development and maintenance of the hospital’s organisational culture is the

responsibility of the various stakeholders of the organisations which include

doctors, nurses, management and patients, however, the key responsibility belongs

to the management. To understand the organisational culture of study hospitals

there are six dimensions used as presented in Table 3.11.

Nearly 33 per cent (strongly disagree 6.3 per cent and disagree 26.8 per cent) of the

staff disagree that the hospital extends complete support to the employees. It is

exactly one third of the respondents to say that the hospital does not support various

activities they perform, and provide physical and emotional support to the

employees. In the absence of proper support from the management the employees

find it more difficult to bring about changes or introduce standards, or initiate any

progressive activity.


staff disagree with the notion that the hospital ensures that the staff is competent in

work processes and management of work. This shows that the hospitals are limited

in their approach towards developing the staff’s competency. There are no regular

programmes to monitor and evaluate the nurses’ performances, and provide

feedback to the employees, and there is an absence of regular training programmes

to train them. Learning organisations try to ensure that the employees constantly

learn and understand the various processes. Also the management should make sure

that the staff members are involved in developing the work processes and simplify

it for better management of patient care.

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Table 3.11

Organisational culture

Variables Grading

Present designation

Total Staff Nurse Sister

incharges

The hospital extend the complete support to the employees

Strongly disagree 16 (6.1) 4 (7.5) 20 (6.3)

Disagree 72 (27.3) 13 (24.5) 85 (26.8)

Agree 53 (58.01) 30 (56.6) 183 (57.7)

Strongly agree 23 (8.7) 6 (11.3) 29 (9.1)

Hospital ensures that the staff competency in work process and management of work


Disagree 49 (18.6) 12 (22.6) 61 (19.2)

Agree 67 (63.31) 33 (62.3) 100 (63.1)

Strongly agree 36 (13.6) 8 (15.1) 44 (13.9)

We always work together in serve the patient


Disagree 7 (6.41) 3 (5.7) 20 (6.3)

Agree 155 (58.7) 26 (49.1) 181 (57.1)

Strongly agree 86 (32.6) 23 (43.4) 109 (34.4)

My hospital leadership is role model for other hospital in the same sector


Disagree 104 (39.4) 16 (30.2) 120 (37.9)

Agree 88 (33.3) 23 (43.4) 111 (35.0)

Strongly agree 32 (12.1) 9 (17.0) 41 (12.9)

The hospital provides effective communication to all concern and creates better interpersonal relations among the staff.


Disagree 71 (26.9) 13 (24.5) 84 (26.5)

Agree 133 (50.4) 29 (54.7) 162 (51.1)

Strongly agree 38 (14.4) 10 (18.9) 48 (15.1)

The hospital never break the rules and ethics which have laid down


Disagree 75 (28.4) 20 (37.7) 95 (30.0)

Agree 129 (48.9) 21 (39.6) 150 (47.3)

Strongly agree 38 (14.4) 9 (17.0) 47 (14.8)

Total 264 (100) 53 (100) 317 (100)(Figures in brackets indicate the per cent of nursing staff) N=317

Nearly 91 per cent of the staff agreed that they work together to achieve patient

care. It shows that the nursing staff are unanimous in their feelings on working

together to achieve patient care. This is a good indicator. It could be noted that there

is a high scope for team work in the organisation. This culture has to be encouraged

and strengthened and used for better patient care.

170

Nearly 52 per cent (strongly disagree 14.2 per cent and disagree 37.9 per cent) of

the nursing staff disagree that their hospital leadership is the role model for other

hospitals in the same sector. It shows that the nursing staff expect some active role

and participation from the leadership to provide guidance, problem solving,

resource availability, professional development etc. Also the present organisational

climate and culture is not favorable. The role model emphasises various qualities

which are expected from the leadership of the hospital because the staff members

expect a good role model to follow for developing themselves.


staff disagreed that the hospitals provide effective communication to all concerned

and create better interpersonal relationships among the staff. Effective

communication and interpersonal relations across the staff and between the staff

and patients is very important. These are the activities that usually the management

has to constantly focus on to maintain and develop the organisation. In the absence

of effective communication and interpersonal relations in the hospital there would

be a high demand for better patient care and a development of better culture.


staff have disagreed that the hospitals never break the rules and ethics which have

been laid down. There is some possibility of a slight change in the rules while

applying them to the staff members. This may cause some resentment among the

staff. If the staff members continue to see or experience such a situation they get

frustrated and it will hamper patient care. This factor is also the source for

demotivation among the nursing staff. Further, it is a strong source for the

organisation’s cultural damage and there is no scope for developing or maintaining

a healthy culture within the organisation. Finally, the management is responsible for

introducing, maintaining and developing a better climate and culture within the

organisation.

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G. Self-perception of performance

The nursing staff’s performance is basically the outcome of their own satisfaction,

patient satisfaction, and the achievement of the hospital objectives. Performance is

defined as “A quantitative measure characterizing a physical or functional attribute

relating to the execution of a mission/operation or function”. Similarly,

“performance is the accomplishment of work assignments or responsibilities and

contributions to the organizational goals, including behaviour and professional

demeanor (actions, attitude, and manner of performance) as demonstrated by the

employee’s approach to completing work assignments”. Accordingly the

performance is an employee's accomplishment of the assigned work as specified in

the criteria and as measured against the standards of the employee's position. The

key dimensions associated with the nursing staff performance are capacity to

perform, willingness to perform and the opportunity to perform. The nursing staff’s

capacity to perform depends on the nursing staff’s ability, age, health, skills,

intelligence, level of education, endurance, stamina, energy level and motor skills.

The willingness to perform depends on motivation, job satisfaction, job status,

anxiety, legitimacy of participation, attitude, perceived task characteristics, job

involvement, ego involvement, self-image, personality, norms, values, perceived

role expectations, feelings of equity,. the opportunity to perform, equipment,

material, and supplies; working conditions; action of coworkers; leader behaviour;

mentorism; organisational policies, rules and procedures; information; time; and

pay.

Performance measurement

Outcomes are often preferred for measuring system performance, but because many

factors can influence outcomes besides nursing care, correctly interpreting outcome

measures requires appropriate controls for these other factors, controls that can be

difficult to implement. At the other end of the spectrum, structural measures are

often viewed as too rigid and because many processes can affect how structure

influences outcomes, making structure an imperfect substitute for how the system is

performing. Process measures, like structural measures, are often easier to measure,

but their connection to patient outcomes must be validated (Eddy 1998) and their

strength is dependent on their association to clinically tested practice guidelines and

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patient outcomes. This requires an evidence-based approach that is currently

limited.

There are four components which can help to measure performance that include

clinical utilization and outcomes, financial performance and condition, system

integration and change, and patient satisfaction (McGillis Hall 2002). A wide range

of factors have been proposed as key influencers in the performance of nursing.

They fall into four broad categories: nurse training and competencies, physical plant

and structure, nursing organization, and work environment and culture. Since all

these factors have wide ranges and need evidence based outcome, it is decided to

understand the nursing performance through self perception process. The key

dimensions that are used to understand self perception of the nursing staff’s

performance is knowledge, ability to handle the work load, ability to handle the

patients, punctuality and attendance, interpersonal relationship, and future potential

development of nurses. These details are presented in Table 3.12

Nearly 52 per cent of the nursing staff feel that their knowledge on their job is good,

while 39 per cent of the staff feel that their knowledge on their job is very good.

This indicates that the staff members are very positive about the knowledge they

posses. The knowledge level would help better nursing care and safety for the

patients. Nearly 44.2 per cent of the nursing staff feel good about their ability to

handle the work load placed upon them, while 53 per cent of the staff feel very

good about their ability to handle the work load placed on them. This shows that

the nursing staff are confident of their ability to handle the work load which they

are entrusted with from time to time. Since the majority of the nursing staff are

experienced they have learnt to manage the workload effectively.

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Table 3.12 Nursing staff’ perception on their performance

Variables Grading Present designation

Total Staff Nurse Sister

incharges

Your knowledge about your job

Poor 1 (0.4) 0 (0.0) 1 (0.3)

Average 20 (7.6) 7 (13.2) 27 (8.5)

Good 140 (53.0) 24 (45.3) 164 (51.7)

Very good 103 (39.0) 22 (41.5) 125 (39.4)

Your ability to handle the work load placed upon you

Average 8 (3.0) 2 (3.8) 10 (3.2)

Good 120 (45.5) 20 (37.7) 140 (44.2)

Very good 136 (51.5) 31 (58.5) 167 (52.7)

Your ability to handle the patient

Average 5 (1.9) 2 (3.8) 7 (2.2)

Good 115 (43.6) 21 (39.6) 136 (42.9)

Very good 144 (54.5) 30 (56.6) 174 (54.9)

Your view about your punctuality and attendance at work

Poor 1 (0.4) 0 (0.0) 1 (0.3)

Average 12 (4.5) 6 (11.3) 18 (5.7)

Good 111 (42.0) 14 (26.4) 125 (39.4)

Very good 140 (53.0) 33 (62.3) 173 (54.6)

Your inter-personal relationship with colleagues and co-workers

Poor 0 (0.0) 2 (3.8) 2 (0.6)

Average 6 (2.3) 0 (0.0) 6 (1.9)

Good 108 (40.9) 19 (35.8) 127 (40.1)

Very good 150 (56.8) 32 (60.4) 182 (57.4)

Your estimate about your own potential to develop further as professional

Very poor 2 (0.8) 0 (0.0) 2 (0.6)

Poor 2 (0.8) 0 (0.0) 2 (0.6)

Average 28 (10.6) 4 (7.5) 32 (10.1)

Good 126 (47.7) 24 (45.3) 150 (47.3)

Very good 106 (40.2) 25 (47.2) 131 (41.3)


Nearly 43 per cent of nursing staff feel that their ability to handle the patients is

good while 55 per cent of the staff feel that their ability to handle the patient is very

good. This shows that the staff members are highly competent to take care of the

patients in their custody. Nearly 39 per cent of the nursing staff feel good about

their punctuality and attendance at work, and 55 per cent of the staff feel very good

for the same. This shows that the nursing staff are conscientious about their work,

value time, and are able to do their work in time.

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Nearly 40 per cent of the nursing staff feel that their interpersonal relationships with

colleagues and co-workers is good, while 57 per cent of the staff feel that their

inter-personal relationship with colleagues and co-workers is very good. This shows

that the nursing staff are able to achieve team work and effect a better performance

through coordinated efforts. Nearly 47 per cent of the nursing staff feel that their

estimate about their own potential to develop further as a professional is good,

while 41 per cent of the staff opine that their potential is very good. This shows that

the nursing staff expect themselves to be better professionals and there is a high

scope for them to develop their skills and abilities.

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