RESULTS
4.1 Qualitative Results on Scale Development
4.1.1 The Factors of Job Demands
CHAPTER 4
Technology is changing and more complicated. I have been updating my knowledge over ten years since I started this career. Now I can professionally predict the symptoms of patients and alert doctors quicker than before.” (Nurse No.2)
“Once I was working as a nurse in a business development in charge of check- up package appraisals. I had to know profoundly about medical equipment, medicine costs, and medical treatment costs. Also, I had to coordinate several divisions and various doctors in order to come up with each package…It is a sophisticated job that needs a clear understanding of details. I have to thank them that present great difficulties for me. After finishing that job, I can work anywhere.” (Nurse No.1)
However, job complexity without understanding or support from supervisors could exert intolerable on nurses. The same nurse further explained “I learn a lot from this job but the responsibility was so high that I was under enormous pressure. When I had problems with doctors [about the treatment costs of each package] and I reported to my boss, he always kept saying “Handle it!” or “Fix it!” He did not understand me.
I cried a lot and, finally, went to the HR department and filled out the resignation letter.”
Job variety
Job variety could be described as a wide range of responsibilities (e.g., medical procedures, training and development, patients’ payment, and quality assurance), a wide range of roles in a position (e.g., managing, supervising, and operating), and new tasks that nurses have to manage. Some nurses considered the variety to be opportunities for development.
“I am a charge nurse and I have to be responsible for 32 rooms at one time.
Each patient has at least two to three problems. At the same time, I have to train new nurses…My responsibilities are not limited to nursing care or nursing management. I belong to a journal club and have to present at least two interesting cases a month to other nurses. Though I am responsible for various types of jobs, I still think that it is an opportunity for learning.” (Nurse No.5)
“It is challenging when I am assigned to a new task. Exactly, anxiety would be my first reaction but I can gradually adjust myself to the task and carry out more duties within the same amount of time.” (Nurse No.6)
On the other hands, some nurses considered some aspects of their jobs unnecessary which in turn could affect their health and became a barrier to succeeding at work because nurses could not handle all aspects of their jobs effectively.
“Each nurse has extra jobs depending on the level they belong to. For instance, in level 3, nurses have to study and present interesting cases each month and these extra jobs lead to more sleep deprivation which can reduce their work quality.” (Nurse No.2)
“With position comes responsibility. As a supervisor, I have to know more than medical procedures, such as staffing, nurse management, or damaged instrument reduction. Also, I have to force other nurses to follow the hospital’s policy. I come under pressure to do all these things and too much pressure is an obstacle.” (Nurse No.9)
Heavy workloads
Key informants reported that because of the nurse shortage in Thailand, even private hospitals could supply each nursing team with fewer employees than required.
Consequently, the remaining nurses overburdened with work. However, some participants still considered heavy workloads to be opportunities not less than threats.
“It seems that everything is waiting for me [a charge nurse]. It is more than I could handle but it is a chance to learn and develop. I believe I can handle it better next time…10%-20% of it can be an obstacle because I expect good quality of work which I could not achieve. However, the knowledge that has gained from previous experiences helps deal with workloads better next time. I know better how to prioritize my tasks.”
(Nurse No.5)
On the other hand, the heavy workload could be regarded as work obstacles because nurses would spend less time to receive training, to sleep, and to spend with their family, and could suffer from physical, psychological, and mental fatigue which probably led to health problems and disengagement from work.
“When I cope with a heavy workload, there is a conflict in my mind. It is kind of like I can do it but why it is so heavy. It rather affects attitudes towards my job. It is sort of like I am not willing to do it but I have to get it done.” (Nurse No.6)
“If I do not get my work done, I have to bring it back and work at home. I could not sleep unless I get it all done. It forces me to have less sleep which affects my energy to work in the next day.” (Nurse No.8)
“In private hospitals, a major obstacle is lack of time. Apart from working in hospitals, we do not have time to do other things. We [nurses] have no time to gain new knowledge or succeed in anything except for working. For example, when I was working in Hospital D, I had no time to study a Master’s degree. I barely have strengths to do anything in my holidays. I had never taken all days of annual leave which I was entitled to. I had more than 100 overtime hours but the policy did not apply to the overtime pay of management levels. I did not know when I could take days of annual leave or used my overtime hours. There always was something going on when I wanted to take time off, such as special meetings or VIP patients.” (Nurse No.1)
Time pressure
Time pressure can be considered to be a part of the heavy workload. Time pressure, in turn, causes anxiety over and action of making mistakes. Both the anxiety and the action are an opportunity (e.g., safety increases, and learning from mistakes which help make preventive plans for the future), as well as a hindrance (e.g., distraction, slowing down working process, and stress increases) to succeed in the workplace.
“Sometimes we are not able to be as quick or responsive as patients expect.
What we could do was solving the problems one by one. Fast and responsive services are what we can learn and we can reap the benefit of it in the future.” (Nurse No.4)
“When we rush to service our patients, normally we feel bad in the beginning because we feel tired. Then we can see the advantages of it. It makes us work better and faster….When we have a feeling that some mistakes might happen, we lose our
concentration which reduces our performance. The growing stress impedes our progress but we can learn from such situations.” (Nurse No.6)
“Sometimes I make some mistakes but I learn that if I rush, I will make such mistakes again. I cannot slow down my working speed but those mistakes are preventable in the future.” (Nurse No.7)
“Anxiety of making mistakes helps me working with more cautious. Also, I have to find out more information, and make more careful preparation.” (Nurse No.8)
Long working hours
Nurses’ normal working hours, eight hours a day, five days a week, seemed not very challenging, nor threatening because nurses could naturally cope with this acceptable level of the inherent stress. However, long working hours could create strong pressures due to weariness and having less time to regain their energy (e.g., sleep or recreation) which might lead to health problems or family conflicts.
“I work 12 hours a day with 2 breaks, a total of one and a half hours. I get tired of working 12 hours. However, ward nurses work harder than me. We have to work 12 hours but ward nurses work longer than that. They start working at 7 in the morning but finish working 9 at night. They have to finish their work before they can go home. It is so tiring and these become an obstacle.” (Nurse No.6)
“Long working hours affect my health. I am old now. Sometimes working long hours could slow down my physical and cognitive performance. (Nurse No.5)
Although long working hours disturb nurses’ lifestyle (e.g., family, pleasure, or leisure), some nurses could mentally and physically adapt to and consider them opportunities to possess mastery or achieve both hospital and personal goals (e.g., extra monetary returns).
“I work from 8 a.m. to 8 p.m., five to six days a week. I have less time than before to take a rest. But I get accustomed to it…. It is an opportunity to learn because there are many types of problems in OPD. If I can get it all done, I will gain more experience.” (Nurse No.10)
“I work 12 hours a day, 4 days a week, but normally I work 1 to 2 days of overtime a week because of understaffing. I am still young and working 12 hours does not make me too tired. My friends from other departments are not different. Most nurses carry their own financial burden so they work more than 100 hours of overtime a month.” (Nurse No.3)
Rotational shiftwork
The schedules of nurses in OPD rotated in accordance with monthly set schedules. For instance, in the same week, OPD nurses might work on a morning shift on Monday, an afternoon shift on Tuesday, and a night shift on Wednesday. These affected nurses’ sleep quality and relationships with family and friends.
“Today I work a night shift and sleep in the next morning. Tomorrow I work in the afternoon and have to sleep at night so my sleeping time always rotates. Some nurses have sleeping problems which affect their health and cause irritability. Some nurses have to take sleeping pills because they are afraid that they could not sleep.”
(Nurse No.2)
“In the past, I used to work in a rotational shift work. Sometimes, I worked in a night shift but could not sleep in the next morning so my health started deteriorating and I was sleepy at work.” (Nurse No.9)
For some nurses, shift work rotations became a problem at the outset. Once nurses got accustomed to this work condition, they no longer caused troubles with them.
“I have to work on holidays when my friends [who pursue other careers] have the day off. So I have to go anywhere by myself. While I was studying, I still had time to hang out with my friends. But now I even rarely go back home to see my family because of no long holidays. I rarely see my friends. It makes me think about why I have to work like this. In the beginning, I considered quitting this job and looking for a nurse position in schools so our days off would be the same as those of my family and friends. It was a small obstacle at first.” (Nurse No.7)
Problematic patients
Straightforwardly, difficult patients were patients who are fussy or high maintenance, had over-expectations of service quality, did not follow treatment plans, or did not pay for treatment fees. These caused nurses’ stress, anxiety, and bad temperament, as well as prevented nurses to feel a sense of achievement (e.g., patients’
recovery slower than it should have been).
“High maintenance patients cause me bad temper and these negative emotions slow down my working process. For example, instead of talking to them straightforwardly what they have to do this or why they cannot do that, I, who is being angry, have to choose appropriate words to calm the patients down.” (Nurse No.6)
Conversely, difficult patients could become challenging work circumstances that nurses could make a plan to deal with and learn from. These become new skills that they could apply in the future in their personal and professional lives.
“When patients ask for whatever we cannot provide, I think it is an opportunity to practice refusal skills which do not hurt their and my feelings.” (Nurse No.9)
“Patients make me stressed. As a manager, I have to deal with all problems…I am proud that I can help my subordinates solve the problems that they encounter and, finally, patients trust us and come back to the hospital again. Different people have different thoughts. I can let it go…It seems to me that customers’ complaints are useful advice.” (Nurse No.8)
Problematic relatives
The characteristics of problematic relatives were, for instance, temperamental, garrulous, strict about medical treatment expenses, uncooperative with the safety regulation or treatment plans, as well as have high expectations of services. Some nurses had negative attitudes towards pointless problems that patients’ relatives created.
“Patients’ relatives can put more pressure on us than patients do. Instead of taking care only patients, we have to spare relatives our time. Mostly, the number of relatives are much more than that of patients. Sometimes, instead of helping, they intend
to cavil at our service. It is a nonsense….Sometimes, we have to allocate nurses to handle relatives as equal as or more than ones to take care of patients.” (Nurse No.8)
Some nurses, also, had negative attitudes towards this issue but could reap some benefits of these circumstances.
“Problematic patients who do not allow us to do what we need to do can be considered challenging because we will develop skills to deal with such people. On the other hand, it can be seen as hindering because it is detrimental to the patients….For example, relatives wanted us to take patients who really needed special care out of ICU to a common room. In addition, the relatives refused to turn on the lights in the room so we could not see even the patient’s face. These hindered the effective delivery of nursing care. Some relatives are very strict about the treatment costs which hinder our working.” (Nurse No.2)
“Patients’ relatives who ask lots of questions might delay our services. But we understand that they are worried about the patients and want the best nursing care from us. On the other hand, I learn how to handle such relatives.” (Nurse No.3)
Understaffing
Key informants reported that because of the nurse shortage in Thailand, even private hospitals could not replace resigned nurses promptly and some nursing teams lack a number of members. Nurse understaffing could lead to patients’ and their relatives’ complaints, weariness from working longer and having less private time.
“Understaffing is an obstacle more than an opportunity to learn because we do not seem to make much progress which will be followed by complaints from head nurses or patients.” (Nurse No.2)
Some nurses understand that understaffing is an inevitable problem for each hospital. If their workload is not usually heavy or if they could manage their heavy workload, understaffing was not an obstacle to work.
“When our team is understaffed, I am unable to be away on holiday and travel to different provinces or abroad. My kid wants to go to Japan but we have to wait until the hospital can recruit new nurses and until those nurses are ready to work. This is not
a barrier to work but it causes stress of having not enough rest which might affect my health but not my work… I know that they are recruiting new nurses. Understaffing is not an obstacle because in the course of a heavy workload, I [a supervisor] will ask nurses to work overtime and our head nurse understands it.” (Nurse No.9)
Incompetent or uncooperative nurses
Incompetent or uncooperative nurses are nurses who neither have necessary competencies to perform the job nor pursue the same policy (e.g., providing the best service). This type of nurses intentionally and unintentionally made other team members unable to work smoothly.
“Sometimes, it is stressful to influence my team to adopt hospital policies. It is boring to tell some nurses basically the same things ten times and they still repeatedly make the same mistakes. If my subordinates could not work as I want it to be [according to the policies], my supervisor will blame it on me” (Nurse No.9)
Some participants regarded this as both challenging and hindering experiences.
“I [a charge nurse] have to train new staff members because they are not familiar with the working process here. Some members are so incompetent that I wonder how they graduated in nursing science. Patients often complain about the service quality of those members so I have to deliver nursing care for them instead of carrying out my own duty… Supervising new members is an opportunity for me to possess the mastery of medical procedure because I repeatedly do the same things until I do it professionally.” (Nurse No.5)
Unfairness
The issues of unfairness that nurses experience are relevant to the superior’s negligence in implementing some policies, as well as favoritism. These affected nurses’
morale followed by non-cooperation among nurses in a team.
“When there was understaffing of nurses, I had to perform duties in that unit and resumed working my own job after that. According to the hospital policy, I should have earned more money for working extra hours but my boss has never implemented
the policy. It is an obstacle because I get tired and disheartened. If I do not earn more money, I do not know why I have to work overtime.” (Nurse No.8)
“When other nurses are late, I have to work more. I can handle more workload but I grow disheartened because these nurses have never been punished for being late.
I am disappointed with my head nurse not being able to handle it.” (Nurse No.10) Some nurses regarded unfairness as a delicate matter that they had to pay attention to maintain the good morale of team members.
“Favoritism is a challenging issue. Sometimes I am just closer to some subordinates than the others so I bought them some snacks and this incident raises doubt about the fairness within the team. Since then I have not bought snacks for any team members. It is so challenging and I have to be more cautious when it comes to this issue.” (Nurse No.9)
Conflicts within and between departments
Conflicts in the workplace could arise within and outside the department.
Within-department conflicts could be arguments between members of a team.
Alternatively, the conflict between departments arose in the form of the ignorance of a request, the delay in responding to a request, or the avoidance of responsibilities. This kind of work circumstances could reduce both individual and team performance.
“The conflict within the department is, for instance, when I tell my subordinates to do something but they do not do it, I have to tell them the underlying reason why I ask them to do so. These cause stress. Sometimes I ask my supervisor to deal with these nurses but she still could not handle these and finally, the problem comes back to me again.” (Nurse No.9)
“HR does not know and fail to recognize the importance of what I need to know.
HR denied my request for attending a specific training. They do not even know that I have to know about it. After that, I contacted the director of the hospital directly [to ask for the permission and the financial support to attend the training] and that made HR dislike me because they think I went over their head.” (Nurse No.1)
Although being unable to end the conflicts, some nurses learn to live with it.