Job satisfaction among nurses is a critical component of hospital management and often determines whether nurses choose to remain in the profession or in the facility where they work. Job satisfaction can be defined as ‘how people feel about their jobs and different aspects of their jobs’ (Spector, 1997:2) and, hence, it is largely an attitudinal variable. Such attitudes improve when employees have positive feelings towards their working conditions (Sojane et al, 2016). Many variables affect a person's job satisfaction, including factors relating to autonomy, organisational limitations, management issues and recognition in the form of, for example, opportunities for advancement.
According to Curtis and Glacken (2014), job dissatisfaction implies that there is a problem that is closely linked to the job or the employee, and managers are required to evaluate their institutions to identify the causes of such problems. Hence, hospital management needs to be attentive to the levels of job satisfaction of their nurses to prevent high turnover rates, and they need to put in place precautions to prevent this from happening (Sabanciogullari and Dogan, 2015).
Job satisfaction and the working conditions of professional nurses are interlinked and it is the role of management to adequately manage these conditions to enhance the job satisfaction of the nurses (Manyisa and van Aswegen, 2017). Cohen et al (2009) cite a number of sources that emphasise the need for leadership to create an environment within which professional nurses are acknowledged for what they bring to the healthcare institution and that enabling nurses to provide high-quality care is critical to maintaining their job satisfaction, and will also encourage nurses not to leave the profession.
Nurse unit managers are key figures regarding staff retention and job satisfaction among hospital staff, particularly registered nurses (Duffield et al, 2011). In South Africa, as in countries such as Australia and New Zealand, a unit manager is a professional nurse who is responsible for a ward or unit in a hospital. See Box 1 for differences between UK and South African nursing staff roles and their titles. When they consult with staff and provide positive feedback it, can lead to an increase in job satisfaction among their nursing staff (Duffield et al, 2011). In addition, Cohen et al (2009) found that high levels of supervisor support were associated with greater retention of registered nurses. This study sought to explore and describe the perceptions of nurse unit managers in public hospitals regarding the job satisfaction of nurses who are under their direct supervision.
| UK nurse category | SA nurse category |
|---|---|
| Charge nurse/ward manager | Unit manager |
| Registered nurse (nurse) | Registered nurse (4-year diploma/degree) |
| Nursing associate | Staff nurse (3-year diploma) |
| Healthcare assistant | Healthcare assistant (6 weeks–6 months) |
Methods
Design
An exploratory-descriptive qualitative design was used in this study. Gray et al (2017) described exploratory-descriptive research as that conducted to address an issue or solve a problem.
Participants
Participants were selected from four public hospitals in the Eastern Cape, South Africa, using purposive sampling. Purposive sampling can be described as a non-probability sampling strategy, whereby subjects are selected because they are deemed representative of the population (LoBiondo-Wood and Haber, 2018). The inclusion criteria were nurse unit managers working in public hospitals in general ward settings, supervising two or more nurses. In South Africa, public hospitals are state owned and managed by the department of health of each province (Jardien-Baboo, 2014). The sample consisted of 14 nurse unit managers who met the sampling criteria. The gatekeepers were the area managers who helped with recruiting potential participants.
Data collection
The participants were interviewed at four hospitals in June 2017 by one of the researchers using a semi-structured interview guide. The following statements were addressed to the unit managers:
Face-to-face interviews in English were recorded on a digital recorder lasting 20–45 minutes in rooms on hospital premises that ensured privacy. Field notes were taken during the interviews. Data saturation was achieved after the 12th interview. Data saturation occurs when no new data emerges from the interviews, or when data begin to be redundant and no new themes can be found (Gray et al, 2017). Data saturation was confirmed by interviewing an additional two participants, with no new themes emerging.
Ethical considerations
Ethical approval was granted by an independent review board affiliated to a local university that has been authorised by the state to provide ethical approval. Participants took part on a voluntary basis and were informed that they could withdraw from participating at any time. Each participant received a letter explaining the aim of the research and their role in the study. Written consent was obtained and participants agreed to be interviewed and digitally recorded. The participants were assured of the anonymity and confidentiality of the interview data and subsequent reports.
Data analysis
The data were analysed using Tesch's (1990) method of data analysis, which involves eight steps, namely:
The researchers discussed each of the themes and subthemes generated by each of the team members before reaching a consensus on the final set of subthemes and themes.
Rigour
Descriptive field notes were captured after each interview. All five researchers acted as co-coders and analysed the data independently and as a team until an agreement was reached regarding the themes and subthemes. An independent coder who was not part of the research process helped to validate the findings.
Results
After data analysis four themes became evident:
Subthemes were identified within the four main themes.
Theme 1: staff shortages lead to nurses feeling overwhelmed and frustrated
A major discussion point raised by the unit managers was the problem of staff shortages. These lead to unmanageable workloads and are caused by inadequate numbers of registered nurses as well as support staff, often exacerbated by high rates of absenteeism. This in turn leads to health problems, such as burnout and depression, among registered nurses.
Subtheme 1: unmanageable workloads of nurses impact negatively on care provided
The managers felt that registered nurses under their supervision were overwhelmed with the workload they were confronted with each day. The staff–patient ratio was wholly inadequate and this made it difficult for nurses to properly monitor the activities of their patients which undermined the safety aspect of their work.
‘They feel that their workload is too much for them. For instance, during the night there is [sic] 3 nurses: one registered nurse, one staff nurse [and] one nursing assistant nursing 45 patients.’
Subtheme 2: lack of support staff leads to frustration among nurses
Unit managers highlighted the situation of role conflict that registered nurses were confronted with daily. Such role conflict was largely a result of staff shortages in non-nursing fields, such as general assistants, pharmacists, clerks and messengers.
‘So, a lot of times the staff had to … escort the patients to [name of hospital]. So, in the end, the few that are remaining can't cope with the workload so they become very, very despondent.’
Subtheme 3: nurses experience health issues such as burnout due to multiple inter-related factors
Unit managers expressed concern that the nurses under their supervision were at risk of burnout and depression, largely due to a lack of staff. They felt that the kind of work that they were exposed to was of such a nature that it would lead to, or at least exacerbate, chronic diseases.
‘They will be burned out, they will develop illnesses, diseases, I mean depression, you name it. They will develop it. And currently we have a few people—bipolar, depression … And we have a lot of staff with chronic illnesses. Hypertension, diabetes, so …’
Subtheme 4: absenteeism is an ever-present problem impacting on nurses' morale
Most of the unit managers highlighted the problem of absenteeism. They indicated that it was almost chronic and that it added to the problem of staff shortages. They described the malicious nature of absenteeism, whereby staff would take sick leave in response to another staff member who had taken sick leave prior to them, and this had a negative impact on morale.
‘And staff will book themselves off if they are not happy… They see this one is taking too much [time] off. Next time is my turn, I will book myself off if they see there is conflict and it's not being resolved for them.’
‘Or sometimes what dissatisfies the people and lets their morale be a bit down is when one or two staff members keep on being absent, not coming to work …’
However, for many of the nurses, their motivation to stay away from work was due to exhaustion as the result of overwork, and they chose to stay away from work because they were tired and feeling overwhelmed.
‘Working under these conditions is not healthy for anyone, and you do not blame people when they are off sick—they [are] tired, they [are] tired, really.’
Theme 2: nurses' work performance is undermined by limited resources and poor infrastructure
A challenge encountered by the nurses was due to limited resources (equipment and medical supplies) and infrastructure (the physical environment in which they worked). These impacted negatively on their work, leading to frustration and poor morale.
Subtheme 1: equipment shortages and poorly maintained equipment frustrate the nursing process
A further challenge highlighted by the unit managers was the problem of equipment shortages and poorly maintained equipment. Basic non-medical equipment such as washing machines were poorly maintained, leading to shortages of linen. Or, for instance, poorly working cot sides led to other concerns.
‘… but we have ordered some cot sides and then, because of the department, it always chooses the cheapest quote, the cot sides is [sic] of poor quality, so if it's a restless patient you struggle to restrain the patient and also to keep the patient in bed with the poor cot sides. … and you know, if the patient falls out of bed, it's a litigation because a patient is not supposed to fall out of bed.’
Subtheme 2: lack of medical supplies prevent nurses from providing high-quality care
The unit managers highlighted the need for medical supplies, but pointed out that the department that supplied these was often short of stock. Simple requirements, such as sourcing adequate, clean linen were found to take up much of the nurses' time and energy.
‘… the sister even told me I stole from another linen trolley, that is what we do. When you get there and you don't see anybody, you just put [it in] a bag and you run away with the bag.’
They also complained that basic supplies such as nappies, waterproof mattress protectors and syringes were not always available. They expressed frustration that stores did not ensure that medical supplies were kept well stocked.
‘It's not always that we are short of other things … we do mainly have basic things, but it's only maybe stores doesn't have nappies, did not have linen savers, they do not have 10cc syringes and all that.’
Subtheme 3: poorly maintained infrastructure impacts negatively on the working conditions of the nurses
The unit managers expressed concern that poorly maintained infrastructure undermined the nurses' working conditions. For instance, a faulty door to a particular ward weakened the safety and security of the nurses working night shift.
‘… our main door is broken. We've asked for repairs. At night, we are sitting with an open system. Anyone can come through, there's a door that doesn't close right down. Anyone who wishes to come in can come in and [it would] be a challenge to three females …. So safety is also another concern.’
A major obstacle highlighted by one unit manager was the fact that the lifts were not working in their multistorey hospital. They had been out of order for over 4 days. Hence, this posed a health and safety risk, particularly for the patients.
‘… look now, the lifts were not working since Friday last week. We have to travel from ground floor to 5th floor—I'm working in 5th floor, you see? That was about … that was Friday, Saturday, Sunday, and Monday. They were just repaired yesterday … patients have to be cancelled for theatre. Then they have to go home and then given other dates.’
Theme 3: discontent among nurses with regard to poor top level and human resource management
Unit managers complained about top level and human resource (HR) management with regard to the lack of communication and poor and slow human resource management processes, which led to frustration among registered nurses. Nurses felt unappreciated and not recognised for their hard work and commitment to their patients. Empty promises from top management led to disappointment, low motivation, frustration and negative attitudes towards the hospital. Nurses questioned top management's awareness of the realities of their working conditions.
Subtheme 1: lack of communication and slow HR processes have significant implications for registered nurses
Unit managers complained of a lack of communication and slow HR processes, which caused frustration among registered nurses. HR appeared to encounter challenges with the provincial government and appeared to blame it for slow administrative processes.
‘I don't know. They [HR] say they didn't receive the documents, meanwhile, when you go to your manager, the manager is saying “no, I have sent the documents to HR” … and HR will say it's Bisho [the provincial government] and all that …’
Participants thought that HR representatives should come down to talk to the registered nurses to explain to them when they would get their money and why they had not received it.
‘If somebody can maybe come, maybe from HR, I'm talking about HR now, if they can just come and then say “guys, your money will be … you'll get your money”. Tell your staff the money will be in at this date and that, and that. We don't hear nothing [sic].’
Subtheme 2: nurses feel that management does not appear to care for them
Unit managers expressed that there was a general feeling among the nurses that management did not appear to care for them and this seemed to be reflected in the lack of perceived support provided. They also felt that management did not seem to appreciate the work they did despite all their efforts.
‘Nobody cares how you do the work, the work must just get done … They want something extraordinary that you have done. Do you understand now that, really, now you feel that they don't appreciate the work.’
Management did not appear to be aware that nurses sometimes experienced abuse at the hands of patients and their families.
‘And we are abused by the patients on the other … (inaudible word) side as well. Of that I can account, because at one stage I was also sweared at [sic] and [they] wanted [me] to be beaten, and some are even beaten by the patients.’
Subtheme 3: nurses feel that the financial remuneration provided is unfair
The unit managers highlighted the problem of financial remuneration for nurses as being unfair. They indicated that some nurses thought that they were being underpaid. They also stated that nurses were not receiving the salary that they deserved, based on their years of service. Often, the process of resolving HR issues took place during working hours and this took the nurses away from their work and added to the pressures brought about by staff shortages.
‘… especially if it's new employees, then they have to battle to get their money put on to the right scale according to the years of service, and then many a time they will spend a lot of time at HR sorting out this issues, whereas they are supposed to be next to a patient at that time …’
Theme 4: despite challenges nurses experience rare moments of satisfaction
The unit managers indicated that the registered nurses experienced job satisfaction when witnessing patients making a recovery. The nurses particularly valued being able to engage in caring and supporting patients outside of the overwhelming number of non-nursing tasks. They also appreciated positive affirmation, appreciation and motivation from the nurse unit managers.
Subtheme 1: witnessing patients recover and hearing their gratitude motivates nurses
The unit managers emphasised the more positive aspects of job satisfaction of nurses at public hospitals. Nurses felt that witnessing a patient recover and hearing their gratification helped motivate them.
‘Say they nurse this patient for a few days, and she'll give a card and thank the nurse for the wonderful work that they have done … it's good for your morale just to hear that the patient was satisfied with what you have given them.’
Subtheme 2: teamwork among registered nurses and nursing support staff is an indicator of job satisfaction
The participants emphasised the importance of teamwork, which had a positive impact on their job satisfaction as nursing professionals. Despite often being overwhelmed by work, nurses were encouraged by the teamwork of their colleagues.
‘[The nurses] care for one another, especially when they are sick, we pray for them and we always try to go and collect them, and go and visit them so that they can feel that they are not … alone.’
Discussion
The nurse unit managers explained how shortages of registered nurses and support staff undermined the job satisfaction of the registered nurses. Such shortages lead to unmanageable nurse–patient ratios and make the provision of high-quality nursing care a challenge (Atefi et al, 2016). Health professionals in low and middle income countries often find themselves undertaking unskilled functions such as mopping floors owing to a shortage of non-clinical staff such as porters or general assistants (Manyisa and van Aswegen, 2017). Staff shortages lead to nurses adopting multiple roles, many of which are unrelated to nursing, which leads to nurses being overworked and a range of psychosocial and physical illnesses such as burnout (Klopper et al, 2012; Manyisa and van Aswegen, 2017). Related to burnout is the issue of absenteeism, a problem highlighted by the nurse managers. Cañadas-De la Fuente et al (2015) stated that high rates of sick leave and absenteeism place an additional burden on an already limited staff. Absenteeism can lead to a decrease in productivity and lower staff morale, as well as reduced patient satisfaction (Mudaly and Nkosi, 2015).
The unit managers voiced their concerns regarding the lack of resources and poor infrastructure in the hospitals where they worked. Lack of resources and poor infrastructure impacted negatively on the workloads and placed even more time constraints on nurses (Mohadien, 2008). In one South African study (Pillay, 2009), nurses were significantly dissatisfied with the resources available to them to provide safe nursing care. Besides shortages of material and human resources, poor physical infrastructure was recognised as a major challenge that undermined the poor working conditions of professional nurses (Manyisa and van Aswegen, 2017). Indeed, poor hospital infrastructure was found to be a mitigating factor motivating South African health professionals to explore emigration (Labonté et al, 2015).
The unit managers stated that the registered nurses questioned top management's awareness of the realities of their working conditions and the resultant implications. The nurses felt unappreciated, exploited and abused by management and government due to the lack of responsiveness to their complaints. In a UK study, it was also found that management was perceived as being unsupportive, with constant changes in policies and practice (Rankin et al, 2016). Furthermore, Manyisa and van Aswegen (2017) argued that management should seek to reduce issues such as unreasonable workloads, because these are major predictors for job dissatisfaction, burnout, fatigue and emotional exhaustion. The unit managers indicated that the nurses wanted recognition for their hard work, commitment and dedication to their hospital and to their patients. Indeed, Pillay (2009) reasoned that hospital managers should seek to reward nurses with non-financial, psychological incentives such as ‘career opportunities, support and appreciation’.
According to the unit managers, the registered nurses experienced job satisfaction when patients recovered or had an improvement in health. They also valued being able to focus on the caring aspect of their job, as well as the teamwork aspect of their work. Indeed, Manyisa and van Aswegen (2017) stated that when communication, interpersonal relationships were fostered between management and staff, and when resources were suitably allocated, this has the effect of creating an environment that enhances quality patient care. If unit managers could utilise these fragments of job satisfaction and enhance them by emphasising the nurse–patient relationship, and also by seeking ways to enhance teamwork among their staff, this could help improve the job satisfaction of their staff.
Strength and limitations
A limitation of the study was that the sample was relatively small and restricted to four public hospitals in one metropolitan area, and thus cannot be generalised to other hospitals. Sociocultural differences prevent the findings from being transferred to other countries. However, the literature demonstrates that the findings are dependable because they are in line with other studies conducted in a range of diverse settings.
Conclusion
The job satisfaction of registered nurses remains a critical discussion point in healthcare institutions and it is necessary for researchers to continue to engage in this focus area. It was useful to obtain the views of unit managers regarding the job satisfaction of the nurses under their supervision because their roles of both manager and advocate often make them aware of the needs of registered nurses. They highlighted issues around staff shortages, limited resources and infrastructure, and poor human resource processes as challenges that undermine nurses' job satisfaction. Although, there were many issues that undermined job satisfaction, there were some factors that enhanced nurses' job satisfaction, namely the recovery of patients and the teamwork occurring between colleagues.