Keywords

Nurses; Working Conditions; Emergency Department

Introduction

Emergency departments are often cited as particularly stressful place, with increasing numbers and acuity of emergency departments’ presentations resulting in high pressure and high-volume workloads [1]. The working conditions are very important to the organization. If the employees have a negative perception of their working conditions, they are likely to be absent, have stress-related illnesses, and their productivity and commitment tend to be low [2]. Organizations where employees are exposed to stressful working conditions, productivity is negatively influenced and that there is a negative impact on the delivery of service. On the other hand, if working conditions are good, productivity increase and there is a positive impact on the delivery of service [2]. Positive work conditions are important in achieving patient and employee safety, quality care and favorable patient outcomes [3]. Healthy work environments involve all practices implemented to attain the highest level of nurse health and wellbeing, quality patient care outcomes, high institutional performance and positive social outcomes [4]. Poor working conditions in any organization lead to feelings of exhaustion, cynicism, and inefficacy, which in turn reduces job satisfaction, increases risks of departure from the organization or nursing practice and has potentially negative impacts on quality of care [5]. Healthy working environments (HWE) enables an employee to live an economically and socially productive life. It, directly and indirectly, affects the safety of patients and a nurse’s commitment and also has been associated with increased nurse retention, job satisfaction, decreased burnout, safer healthcare practices, and better patient outcomes [6].

The aim of the present study is to assess the working conditions of nurses at the emergency departments at governmental general public hospitals in the Gaza strip. The findings of this study were identifying the challenges related to work conditions and this will provide guidance to policymakers to improve the working conditions for nurses.

Research Methodology

Research design

A descriptive-analytical cross-sectional study was used to assess the nurses working conditions at emergency departments at governmental hospitals in the Gaza strip. This method was used by the researcher because it is appropriate for collecting information, data or materials that occur spontaneously occur at a particular time, describing one or more phenomena, establishing relationships and associations between two or more variables.

Setting of the study

The study was conducted at emergency departments at general governmental hospitals at the main general governmental hospitals in each governorate (Indonesian Hospital, Beit Hanoun Hospital, Al-Shifa Medical Complex (medical, surgery department), Al Aqsa Hospital, Nasser Medical Complex, European Gaza Hospital, and Al- Najjar Hospital) in Gaza Strip. The number of emergency departments in government hospitals in Gaza Strip is seven.

The sample

The sample of this study was census sample means that the researcher was selected all the units or members of a population, consisting of all nursing staff, head nurses and supervisors. The sample size was 154 nurses who participated in the study with a response rate of 90%.

Eligibility criteria

The study included all registered nurses who are working in the emergency department, who working formally for at least one year and head nurses and nursing supervisor. The study excluded all volunteers, student nurses and internship students and nurses who working in the pediatric and gynecology emergency department.

Study instruments

The researcher has used one instrument for assessment nurses working conditions at emergency departments at governmental hospitals in the Gaza Strip. The questionnaire includes questions related to personal and sociodemographic characteristic data and questions related to five domains (workforce staffing, workflow design, physical environment, personal factors, and organizational factors) for assessment nurses working conditions at emergency departments at governmental hospitals in the Gaza Strip. All the questions were on five Likert scale range from (1= strongly disagree, 2= disagree, 3= neutral, 4= agree, and 5= strongly agree). The average time for filling the questionnaire took around 10–20 minutes to be completed.

Reliability and validity of the instrument

The questionnaire was sent to a panel of expert persons to assess the clarity and relevance of the questionnaire to the objectives of the study and the researcher was used the Cronbach alpha coefficient to estimate the internal consistency for the study instrument. Cronbach alpha (0.923).

Pilot study

A pilot study (N=30) was conducted to develop and test the adequacy of the research questionnaire before starting the actual data collection as a pretest to determine the real-time needed to fill the questionnaire and identify areas of vagueness, to point out weaknesses in wording and translation to Arabic. To test face validity and to check the internal consistency of the study and modifications of a questionnaire.

Ethical consideration and procedures

Approval was obtained from the Al-Quds University and official approval for the study was sought from Helsinki Ethics Committee. Official permission was sought from the Ministry of Health. Approval was sought from participants, Ethical codes of conduct have strictly adhered at all stages of the study, and confidentiality was maintained. The data obtained in this research were for research purposes only. Participation in this study was voluntary and all data collected remained anonymous and confidential.

Data collection

Data have been collected by the researcher and through some colleagues in hospitals by using a self-administered questionnaire to get information from the eligible nurses about the status of their working conditions at the emergency departments. Participants were asked to fill the questionnaire form, which was distributed during their working hours and break time. 154 of them participated in this study, with a response rate of 90%.

Data analysis

Data analysis was carried out by a statistician and the researcher and analyzed using the Statistical Package for the Social Sciences (SPSS), version 24. The frequencies and descriptive data (means, ranges, percentage, and standard deviations) were conducted to assess the research variables. Bivariate tests (i.e., t-tests, ANOVAs) were used to identify which nurse demographic variables (i.e., age, gender, marital status, place of residence, qualifications, job title, years of experience, weekly working hours, salary and Name of hospital) were related to working conditions at a statistically significant (p<0.05) level.

Results

Socio-demographic characteristics of the study population

Table 1 Distribution of nurses by demographic characteristics (N=154). Showed that half of the nurses (49.4%) were less than 30 yrs. old and most of them are male and married. More than half (56.5%) of the nurses in the emergency departments have experienced between 1 - 5 years and three-quarter (74.7%) of the nurses have a bachelor’s degree. About (74.0 %) of nursing staff work 35 hours per weekend 26.0% work more than 35hours per week. The majority of the nurses (80.5%) receive a salary between 1001-1500 NIS. Also showed that Al-Shifa complex Hospital in Gaza City has the highest (22.8%) percentage of nurses followed by Nasser complex (17.5%), Indonesian Hospital (16.9%), Al-Aqsa Martyrs Hospital 14.3%, Gaza European Hospital (11.0%), Al-Najjar Hospital (9.7%), while Beit Hanoun Hospital was ranked last in the ranking(7.8%).

Table 1 Distribution of nurses by demographic characteristics (N=154).

Table 2 Weighted mean of each working conditions domain shows that the total mean percentage for all working condition domains in the emergency department at governmental hospitals was (63.6%) (Mean=3.18, S.D. =0.34). The results also showed that the highest domain in nurses responses to working conditions was personal factors domain (mean=3.98, S.D. =0.45) with weight mean equals (79.5%), followed by workflow design domain (mean=3.69, S.D. =0.38) with weight mean (73.8%), Workforce staffing domain (mean=3.08, S.D. =0.44) with weight mean (61.7%), organizational factors (mean=2.80, S.D.=0.56) with weight mean (56.1%), and last rank domain was physical environment (mean=2.50, S.D. =0.59) with weight mean (49.9%).

Table 2 Nurses’ perceptions toward working conditions at emergency departments.

Table 3 Differences between work conditions domains and nurses' demographic variables (significant just p<0.05)(Independent sample t-test& One-way ANOVA). Showed by an independent t-test that there are statistically significant differences between gender perception in the third domain (physical environment) (p=0.001) in favor of the female, while there is no statistical significance difference between the rest of the domains.

Table 3 Differences between work conditions domains and nurses' demographic variables (n=154).

The results showed by One-way ANOVA that there are statistically significant differences between nurses' place of residence and (workflow design, physical environment, and personal factors domains), while there is no statistical significance difference between the rest of the domains and place of residence. In addition, there is a statistically significant difference between nurses’ qualifications and (physical environment and organizational factors domains), while there is no statistical significance difference between the rest of the domains and nurses’ qualifications. Moreover, there are statistically significant differences between nurses' job title and (physical environment and organizational factors domains), while there is no statistical significance difference between the rest of the domains and job title.

Table 4 Differences between work conditions domains and nurses' demographic variables (significant just p<0.05)(One-way ANOVA). It showed that there are statistically significant differences between nurses' monthly income and (workforce staffing and physical environment domains) while there is no statistical significance difference between the rest of the domains and monthly income. Also, there is a statistically significant difference between nurses’ workplace (name of the hospital) and (workflow design, physical environment, and personal factors domains), while there is no statistical significance difference between the rest of the domains and workplace (name of the hospital).

Table 4 Differences between work conditions domains and nurses' demographic variables (significant just p<0.05)(One-way ANOVA).

Discussion

The results showed that about half of the study sample was under 30 years old, most of whom are male and married and also found that three-quarters of the nursing staff in emergency departments had a Bachelor's degree. In addition, most nurses working in emergency departments receive a salary that ranges between 1001 to 1500 NIS a month (80.5%) and the results found that 74.0% of nursing staff work 35 hours per week and 26% of the work over 35, an excellent percentage and according to the policy of MOH and the researcher believes they correspond to international weekly nursing hours and this corresponds with the results of the previous study that found that working more than 40 hours a week adversely affects patient safety and the health of registered nurses [7] and with study that found that many negative consequences are associated with working overtime and long hours, including adverse nurse and patient outcomes [8].

The results of this study showed that the domain of personal factors got the first place in the responses of emergency nurses to the five domains because of the constant pressures experienced by the nurse due to increased workload and increase verbal and physical attacks on nursing and lack of continuous training of nurses all this increases the stress on nursing and it agreed with the previous study that showed uneven distribution of nurses and the nurse shortages make the nurses more stressed, increase workload, and promote failure of nurses to perform their duties to their very best. In addition, nurses need continuous training to acquire new skills to work effectively in their work environment [9]. Also showed that workflow design domain got second place and the workforce staffing domain got the third place and this indicates the importance of having a sufficient number of experienced nurse, clear job description and cooperation and communication between nurses and other service providers and patients in the departments and it consistent the previous study that identified important organizational structures such as the leadership and infrastructure, the processes such as work design, supervision, quality emphasis, and group behaviors [10]. Also, it agreed with the results of the previous study that revealed that a nurse’s workload, skill mix, job advancement, and wages were some of the factors that had an influence on healthcare [11]. Moreover, the results found that the organizational factors domain got fourth place and the physical environment domain got the last place. This result is explained by that the physical environment in emergency departments is moderate and this influenced nurses' responses to these factors because the work environment plays a role in employee performance and productivity, as well as organizational factors, affect staff morale in positive and negative ways. This corresponds with the results of the previous study that found an unsafe health facility environment such as unsuitable furniture, poorly designed workstations, lack of ventilation, excessive noise, inappropriate lighting, poor supervisor support, poor workspace, poor communication and lack of personal protective equipment, adversely affect the productivity and performance of the employee [12], and agree with the results of the previous study that showed the importance of good organizational culture and inter professional teamwork [13] and with the results of the previous study which showed that effective communication with nurse leaders, managers, and patients provides a stress-free working environment that results in better care for patients [14].

The results showed that there are statistically significant differences between gender perception in the third domain (physical environment) (p=0.001) in favor of the female. While there is no statistical significance difference between the rest of the domains and this are not consistent with the results of a study [15] which assessed the working conditions of nurses in the surgical departments and did not found significant differences between the working conditions in the surgical departments and the gender of nurses. In return, findings are consistent with the previous study which found significant associations between nurses with regard to work-related stress and gender [16]. And the result showed that there are statistically significant differences between marital status perception and working conditions domains and this not consistent with the results of a study which found significant associations between nurses with regard to work-related stress and marital status because female nurses were more stressed than males; this may be due to female nurses being working mothers who bear a greater and more diffuse workload than men, or all women because they have multiple roles in the family and society [16]. Also, the findings showed that there are no statistically significant differences between working conditions domains and nurses age and this is not consistent with the results of a study [15] which found that there were statistically significant differences between age groups and working conditions in the surgical departments and with study that found that that older age is significantly associated with work-related stress [17]. Moreover, the findings showed that there are statistically significant differences between nurses' place of residence and second domain of working conditions (Workflow Design) third domain (Physical Environment) and fifth domain (Personal Factors). In addition, the results showed that there are statistically significant differences between nurses' qualifications and third domain of working conditions (Physical Environment)and fourth domain (Organizational Factors) and this are consistent with the results of a study [18] which showed that there is statistical significance between qualification and the weakness of the physical environment, which may mean that the lack of qualification of the respondents make them more suffering and they did not agree with the results of a study [15] which found that There were no statistically significant differences between Qualifications and organizational factors. The results showed that there are statistically significant differences between nurses' job title and third domain of working conditions (Physical Environment) and fourth domain (Organizational Factors) and thus agreeing with the results of a study [15] which found that there were statistically significant differences between job title and physical Environment and organizational factors and them did not agree with the results of a study [15] which found that there were statistically significant differences between job title and Workforce staffing.

The results showed there are no statistically significant differences between nurses’ number of years working in emergency departments and working conditions and they did not agree with the results of a study [4] which found that there were statistically significant differences between work environment and number of years spent in the profession. The reason for the difference may be a better adaptation to the work environment and working conditions as professional experience improves. The results showed there statistically significant differences between nurses' salaries and working conditions and this agreement with the results of a study [19] which found insignificant association between more favorable nurse work environments and nurse outcomes, net of wage effects.

Conclusion

The health care working conditions can be a stressful place to work and the working conditions are very important to any employee in the hospitals especially nurses. This study aimed to assess the working conditions of nurses at the emergency department at general governmental hospitals in the Gaza strip. The results indicated that nurses who work in the emergency departments have moderate perceptions about their working conditions especially in relation to workforce staffing, organizational factors, and physical environment. This is due to several challenges in the working conditions of nurses in emergency departments (shortage of nursing manpower in emergency departments, lack of security personnel constantly, the lack of incentives and low salaries, the increase of verbal and physical assault on the nursing staff and the space and size of some small emergency departments).

Recommendations

The results might help in improving the work conditions for nurses at emergency departments at general governmental hospitals. Based on our findings, I recommend to ensure an adequate number of nurses with a staff mix of skills in emergency departments to provide safe and quality health care to patients, effective utilization of the continuing education department in hospitals and providing training courses to update emergency nurse’s information and develop their skills, enhance the scope of practice for nurses based on job descriptions, provide security to personnel continuously at all times, Provide suitable rooms and WC for nurses, recognition and award system should be encouraged, strong communication between management and nurses and communication lines should be open with nurses, effective operation of the Triage system in E.D. and conduct mental health courses for nurses by the mental health department to help them get rid of the psychological pressure resulting from the pressure of work and life.

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