Acta Medica 2013; 2: 29–34
acta medica
ORIGINAL A rtıcle
The conflict between formal and informal structures of the
emergency departments that effect the occupational
satisfaction of staff
Orhan DERMAN1, [MD]
1 Hacettepe University Medical Faculty
Department of Pediatrics
Division of Adolescent Medicine
* Corresponding Author: Orhan Derman
Hacettepe University Medical Faculty,
Department of Pediatrics
Division of Adolescent Medicine
Sihhiye, 06100 Ankara, Turkey
Phone +90 (312) 305 11 60
[email protected]
A BST R AC T
This study addresses the factors that affect the occupational satisfaction of
staff working at the emergency department of hospitals. As high occupational
satisfaction directly reflects work gratification, this will then directly increase
the satisfaction of the patients that apply to the emergency department of the
hospital. Making the emergency department more functional in the health
system leads to the formation of an ordered and more compatible sub-system.
Everywhere around the world emergency departments are the most difficult
to administer hospital services. At these centers the satisfaction level is usually below that of the hospitals average. In this study to measure the level of
work gratification the occupation satisfaction scale was applied. Professions,
age, sex, marital status, working hours, working hours in the emergency department were questioned. Only when conflict between formal and informal
structures of the emergency departments are solved will occupational satisfaction of emergency staff increase, this will in turn lead to an increase in gratification in the work place and cause an increase in the quality of service. Our
study showed a difference of total occupational satisfaction and the most important factor affecting this was found to be occupation.
Key words: Occupational satisfaction, Emergency department, Formal and informal structures
Received 22 January 2013, accepted 4 July 2013
Introduction
In the emergency ward, the patient is in communication with each type of personnel. The patient’s satisfaction of the service received is based on mutual
relationship with the personnel offering these services. The personnel’s motivation and desire determines the quality of these relationships.
The quality of the hospital’s service is represented by this mutual satisfaction of both groups.
Despite the fact that this interaction is mutual, the
current study focused on “personnel job satisfaction”
from a constitutional point of view. Recent studies
on organizational productivity have mostly focused
on employee’s job satisfaction.
From a sociological point of view, a hospital can
be seen as a social system based on the division of labor of doctors, nurses, technicians and administrative personnel, who vastly differ from each other in
levels of education, social status, specialization into
© 2013 Acta Medica. All rights reserved.
age categories. The social system represents an organization of interdependent groups and their activities. In other words, it represents the distinctiveness
that shapes a social system and coordinates its activities towards a common goal [1].
With a constitutional point of view, every social
systems is also an organization and every organization is a team of statuses and roles, shaped in a hierarchical order working synchronously and in coordination with each other [2]. In other words a system’s actions present a relatively integrated structure [3]. In Parsons’ terminology, a social system is
described as ‘A group consisting of individuals working towards the same goal and trying to execute the
same activities’. According to him, the social system
is ‘A structure held together by mutual expectations
that include regulations connected with each other’.
In other words, a system is: “A collection of pieces
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The conflict between formal and informal structures
related with each other that form a whole.” A system patients applied, only 15500 cases were offered
is a balanced structure, consists of pieces named health service between 15th December 2010 and 15th
‘minor-senior system’ that are related with each oth- March 2011. Considering three shifts, an emergener and with the whole. A minor-senior-system has cy doctor cared for 20-25 patients during one shift.
At Hacettepe emergency service, while three docthe ability to sustain itself.
It should be stated that sustaining job satisfac- tors were always in charge during a shift, there was
tion in an organization full of status and role differ- a lack of nurses that intern doctors covered some of
entiations is problematic because every occupation- the nursing duties as well. In all other hospitals conal group has different needs, value orientations and sidered for this study, the number of patients cared
expectations [4]. The hospital environment is strug- for on a daily basis varied between 15-20, additiongling for prolificacy in a conflux of complex patterns ally 6-7 doctors worked at the same time on a single
and expectations. Different expectations, upon job shift. In developed countries, the average number of
satisfaction, must meet on a common ground on ac- doctors caring for patients per shift are limited between 10 and 15, this prevents doctors from offercount of the patient’s health.
The aim of this study was to evaluate the rela- ing crowded emergency services. It is endeavored to
tionship between different status and roles identi- prevent doctors caring for 4 or more patients at the
fied by the formal pattern within a hospital’s system same time. In Turkey, teaching hospitals care for a
and to investigate the level of job satisfaction among number of 35000-100000 patients per year.
hospital personnel. Our key starting point is formal
role definitions inheritably differentiating the job Data Gathering Technique
satisfaction levels on a non-formal level in context of In this study, review of the literature constituted the
the virtual level it makes out. This study focused on starting point. Interview techniques were used to
whether job satisfaction hierarchically differentiat- collect data. A questionnaire was conducted in ored among emergency room medical personnel (spe- der to determine job satisfaction levels and collect
cialist, resident, nurse, secretary, security personnel) data. Job satisfaction scale was used to determine
who promoted getting out of the formal roles and job satisfaction (conducted by Hacettepe Literature
University Faculty of Department of Psychology and
even demanded it in the nature of the job.
its reliability previously established). Job satisfaction
Material and Methods
scale consists of 36 questions; the items and evaluaThe ethical committee permission was taken for tion scales are provided [6].
the study. In this study, hospital emergency wards
The relationship between the qualitative variin Ankara province, namely Hacettepe University ables was evaluated by chi square test. Normal disHospital and Children’s Hospital, Ankara Numune tribution of the data was analyzed using ShapiroHospital, Ankara Hospital and Diskapi Hosptial Wilk test. Differences between two groups were anwere chosen as the sample. These hospitals were alyzed using independent samples t-test and Mannchosen because they are teaching hospitals offering Whitney U test for normally and non-normally disan important service with the number of patients tributed quantative variables, respectively. Kruskal
seen every year. The Job satisfaction scale was im- Walls test was utilized when the number of groups
plemented on 155 hospital personnel. However, only was more than two. The relationship between two
a total of 146 participants consisting of 15 specialist variables was analyzed with Spearman correlaphysicians, 38 residents, 45 nurses, 19 secretaries, 16 tion coefficient.
male nurses, 13 security personnel and 9 people who
Limitations of the Study
left the occupation part blank were evaluated.
In emergency services, high intensity is account- Since the number of personnel and patients who
ed as a crowded emergency service. This defini- accepted participation was limited, this study retion is used when a supervisor doctor cares for 4 mained on a case study assessment level. Even
or more patients at the same time [5]. At Hacettepe though personal survey application and interview
University Hospital, while 9500 patients applied, had been planned for the study, participants’ fear
only 4500 cases were offered healthcare services, for their personal information being exposed and
and at the pediatric emergency service, while 17700 their negative reaction towards this caused a problem in the pilot study. For this reason this method
30
© 2013 Acta Medica. All rights reserved.
Acta Medica 2013; 2: 29–34
of data collection was abandoned and instead surveys were distributed to the participants, and they
were asked to complete them in three working days.
Despite all information given about confidentiality,
because of their fear of exposure some of the participants still did not provide information on sections
such as age, sex and occupation. Therefore, despite
the fact that 155 hospital personnel from 5 different
hospitals were reached, only 117 of them completely filled the survey and the rest of the forms lacked
demographical information. At the beginning of
the study, it was planned to make patient satisfaction surveys for each hospital. However, each hospital has its own patient satisfaction survey and data
is collected and analyzed every year. Therefore permission for another survey to be conducted was denied, consequently, we were informed that results
from hospitals’ own survey could only be obtained
after the second half of the year, thus; patient satisfaction was not included in the research design.
Results
According to the job satisfaction scale used in the
study, there was no direct relation between
age and job satisfaction. However, there was a
statistically significant (P = 0.003) relation between
age and marital status. When compared between
personnel from different departments of the hospital, the marital age for emergency service personnel
was between 20-29 years of age. Therefore, from a
sociological perspective, an emergency service personnel reaches to marital and parenting status, being basic social statuses, at a later age. More extensive and detailed research is needed to investigate
the reasons behind it.
Job satisfaction of the emergency personnel was
not related to sex and marital status. However, a significant relation between the personnel’s occupation
and job satisfaction level was found. In the hospital’s
system, highest job satisfaction levels were attained
firstly by male nurses and secondly by female nurses.
According to the collected data, income was the
most important factor primarily for specialist doctors and secondarily for male nurses among other
occupational groups.
In terms of job satisfaction, among occupational
groups, promotion was primarily an important factor for specialist doctors and secondarily for assistant doctors who wanted to be successful in their respected areas. Male nurses followed this and security personnel came at last order.
© 2013 Acta Medica. All rights reserved.
Derman
When attaining job satisfaction, nurses, secretaries, security personnel and finally specialist doctors and assistant doctors respectively, gave great
importance to consultancy.
When attaining job satisfaction, informal income
was the most important for male nurses and secondly for female nurses. Similarly, attaining job satisfaction in any way while earning informal income in return for the services provided is primarily important
for male nurses. Secondarily for the nurses, security personnel and secretaries. Specialist doctors and
residents are in the last place for this variable.
Among the working groups of emergency services, presenting a situation (constitutional dynamics) while attaining job satisfaction was important
for secretaries, security personnel and male nurses
respectively. On this matter, specialist doctors and
residents were least affected by constitutional dynamics. It is ascertained that collaboration (working
together) was not an important factor for any of the
occupational groups and that the level of job involvement levels was very high among male nurses, secretaries, security personnel and nurses, respectively.
When attaining job satisfaction, male nurses,
nurses, secretaries and security personnel respectively, regarded communication most importantly. For doctors and assistant doctors, this factor was
less important.
In terms of total satisfaction, male nurses attained maximum satisfaction level, then nurses, secretaries, security personnel, specialist doctors and
residents respectively.
In Table 1 the relation between job satisfaction
and variables were presented.
Job satisfaction was related with salary (P =
0.004), with progress (P = 0.015), with supervision
(P = 0.019), with marginal benefits (P = 0.002), with
awards based on certain services (P = 0.001), with
presenting the situation (P = 0.015), with nature of
the job (P = 0.003), with communication (P = 0.001)
and with total satisfaction levels (P = 0.001).
A relation could not be established between job
satisfaction and working together (P = 0.247)
In Table 2, job satisfaction was evaluated according to age, time spent in job, time spent in emergency service with marital status.
A significant relation between marital status
and age was found (P = 0.003); however, no relation between marital status and time spent in the
job and time spent in emergency service was found
(P = 0.092, P = 0.126). This statistically significant
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The conflict between formal and informal structures
Table 1. Job satisfaction of emergency personnel according to their occupation.
Specialist
doctor
Resident
Nurse
Male
nurse
Secretary
Security
personnel
Total
15
38
45
16
19
13
146
Salary
1.00 ±1.36
0.13 ±0.41
0.38 ±0.80
0.94 ±1.06
0.21 ±0.53
0.69 ±1.18
0.45 ±088
0.004
Progress
1.93 ±1.16
1.29 ±1.03
0.93 ±0.88
1.25 ±0.93
0.84 ±0.89
1.08 ±1.03
1.16 ±1.01
0.015
Supervision
2.07 ±1.48
1.87 ±1.52
2.80 ±1.27
3.19 ±0.65
2.53 ±1.64
2.15 ±1.40
2.43 ±1.43
0.019
Marginal benefits
0.93 ±1.16
0.89 ±0.92
1.07 ±1.15
2.19 ±0.83
0.89 ±1.28
0.77 ±1.01
1.08 ±1.13
0.002
Awards based on certain services
0.53 ±0.91
0.47 ±0.86
1.13 ±1.23
2.06 ±1.38
0.95 ±1.07
1.08 ±0.95
0.97 ±1.17
0.001
Presenting the situation.
0.80 ±0.94
0.58 ±0.75
1.07 ±0.80
1.13 ±1.14
1.21 ±0.78
1.15 ±0.55
0.95 ±0.85
0.015
Working together
2.33 ±0.90
2.42 ±1.08
2.82 ±0.96
2.56 ±1.31
2.58 ±1.07
2.15 ±0.89
2.55 ±1.04
0.247
Nature of the job
2.40 ±1.18
1.95 ±1.31
2.89 ±1.17
3.06 ±0.99
3.00 ±1.15
3.00 ±0.81
2.64 ±1.23
0.003
Communication
1.07 ±1.03
0.95 ±1.06
1.89 ±1.19
2.19 ±1.04
1.37 ±1.16
1.31 ±1.31
1.47 ±1.20
0.001
Total satisfaction
13.07 ±7.19 10.55 ±5.34 14.98 ±5.71 18.56 ±5.20 13.58 ±6.26 13.38 ±4.66 13.70 ±6.11
0.001
N
relation between marital status and age, when analyzed according to the personnel’s age groups (20-29
years of age, 30-39 years of age, 40+) and according to
marital status (Table 3); % 60.95 of the participants
between ages 20-29 are single, %18.65 of the participants between ages 30-39 are single and %18.75 of
the participants aged 40+ are single (p <0.05).
Discussion
The primary aim of the healthcare system is to fulfill
the social, material, financial and human resources needs of patients. The role of hospital administration is improving healthcare policies of both patients and workers depending especially upon the
hospital’s needs instead of focusing on centralized
applications. There is a struggle for patients, depending on more responsibility and more competition; for the workers on the other hand, administration focuses on improving their job satisfaction
P
while developing different policies focused on increasing their performances [7].
The aim behind constructing the healthcare system is to improve the quality of human resources
and the system. This is directly proportional to increasing the personnel’s satisfaction.
There are three aspects defining patient, specialist and administration quality:
1. Patient quality: a patient should be open and
willing for treatment.
2. Specialist quality: a specialist should be able to
identify the patient’s needs.
3. Administrational quality: taking care of patients
needs while using minimum resources, politics
and legal applications while ruling out mistakes,
delays and wasting time [8].
One of the most important aspects when putting
forth service quality is the personnel executing it
and their attitude towards the patients and their
Table 2. Job satisfaction according to age, time spend in job, time spend in emergency service with marital status
Marital status
Age (20–40+ years of age)
Time spent (>1 year) in the job.
Time (>1 year) spent in emergency service.
32
Number (n)
Mean ±SD
Married
76
33.64 ±6.22
Single
40
30.10 ±5.795
Total
116
32.42 ±6.28
Married
68
9.00 ±5.38
Single
39
7.08 ±6.01
Total
107
8.30 ±5.67
Married
65
58.06 ±47.97
Single
36
42.81 ±46.96
Total
101
52.62 ±47.94
P
0.003
0.092
0.126
© 2013 Acta Medica. All rights reserved.
Acta Medica 2013; 2: 29–34
Derman
Table 3: Distribution according to age intervals and marital status
Age (year)
Married
Single
Number
%
Number
%
20-29
16
39.03
25
60.97
30-39
48
81.35
11
18.65
40+
13
81.25
3
18.75
Total
77
66.38
39
33.62
relatives. One of the most important variables of formal level (working style being “shifts” in emerservice quality is personnel’s job satisfaction. [9].
gency services and fast, correct and professional apOrganization is a social system and every social proach towards the patient being a heavy work load)
system is designed to meet the individual’s needs. create an informal structure for the emergency perThe ontological existence of a social system depends sonnel (prolonging of marriage age, team construcon the meeting of needs. In other words, a system tion cause by working together) caused by the acthat cannot meet its members’ needs is not efficient tual interaction areas. However, should the margin
and cannot sustain its existence for long. In other between formal and informal structures increase,
sense this means that every individual meets his/ it will always cause problems regarding with sysher own needs in the parameters of that social sys- tem’s efficiency.
tem. On the other hand, in order to sustain its exisIn formal structures, systems always work on
tence, the system should motivate the members so status’ and role hierarchy. Those who occupy high
that they can execute their own roles. Thus, the re- status, have moral rights and more responsibilities.
lationship between individuals and social system all In this study, it was analyzed whether the structural
work together in a symbiotic (mutual dependence institutionalized ideal role definitions caused a hiersystem) manner and so paradoxically, it can trigger archical difference during actual role performances
the system to change. Stress possesses the potential on job satisfaction. Hence, our starting point in this
to change the system, represents the quality of the study was that, according to status hierarchy, job
relationship between individuals and system in gen- satisfaction levels must be hierarchical as well. [12].
eral [10].
An interesting finding in this study was that we
This point of view created our starting point. In could not confirm a relationship between the job
our study, we acknowledged the hospital as a social satisfaction levels and age, sex, or marital status. An
system and this symbiotic and paradoxical relation- increase in age leading to an increase in work expeship between the hospital’s system and the individ- rience and in job satisfaction was an expected result.
uals is accepted as “job satisfaction” in the means of We believe further studies must be conducted to informal and informal structural stress. Because, “job vestigate why this outcome didn’t present itself.
satisfaction” in an occupational organization repOne of the most important findings of this study
resents the overlap of formal and informal structure; was that no hierarchical differences were found bein other words, it is an indicator of the overlap of tween job satisfaction and occupational groups.
individual’s needs and the needs of the system as a This is a finding that shows the system is anomic
whole [11].
all by itself. Because; in a functional hospital sysIn this study, when analyzing basic macro and tem, doctors with the highest prestige are expected
micro problems the individuals might encounter to have primary satisfaction levels. However, in our
in the emergency ward, differences between insti- study, we confirmed that occupational groups with
tutionalized role and status definitions of the emer- the highest job satisfaction levels were nurses and
gency service personnel on a set formal level and male nurses. This shows us that the formal strucemergency role deeds on an informal level, consti- ture of the system and informal structure of the systutes the primary outcome of this study. In brief, tem do not match up. The reason behind this may be
in this study, ideal roles are acknowledged as mac- that doctors are very sensitive about their wage and
ro and real roles are acknowledged as micro vari- the number of patients per doctor is very high. The
ables. However, structural elements identified in results confirmed that financial income was most
© 2013 Acta Medica. All rights reserved.
33
The conflict between formal and informal structures
important for specialist doctors when attaining job
It is confirmed that among male nurses, job satsatisfaction. Another striking point is that male isfaction was relevant with informal income. This is
nurses represented the second occupational group.
another finding that showed how corrupted the sysDoctors’ preference of giving importance to in- tem was.
come while attaining job satisfaction is a damaging
Another salient finding of this study is that confactor for their charismatic leader role in the eyes of sultancy among the hospital’s system holds no imtheir patients. Because while communicating with portance for the doctors while attaining job satisfacthe doctors, patients primarily want to be accepted tion. This finding, combined with the information
as a human being; while doctor’s giving much im- given above, creates a perforce result that in their
portance to money, creates distrust for the patient.
professional fields, specialist doctors prefers subWhen analyzing job satisfaction scale among it- stantial satisfaction to moral satisfaction.
self, values based on income (wages, marginal income, awards based on certain services) affected job Conclusion
satisfaction on the highest level. On the other hand, All these findings presents a necessity that emergenthe effects of consultancy on job satisfaction were cy personnel in hospitals should acknowledge that
relatively low. This shows that, hospital systems run medicine is for the people.
according to capitalist logic.
REFERENCES
[1] Broom L. Selznick, P. Sociolgy: A text with adapted readings
(3rd ed.). New York, NY: Haper&Row. 1963; 746.
[8] Kathleen K. Leader Political Skill and Team Performance.
Journal of Management. 2004; 30: 309–27.
[2] Parsons T. Illness and Role of the Physician. A Sociological
Perspective, American Journal of Orthopsychiatry. 1951; 21.
[9] Konrad T. Interprofessional Collaboration and Job Satisfaction
of Chiropractic Physicians. Journal of Manipulative and
Physiological Therapeutics. 2004; 27: 245-52.
[3] Parsons T. The present position and prospects of systematictheory. In Parsons, T. Essays in socioloical theory. New York;
Free Press, 1954; 212-37.
[4] Goldsmith SB. Health Care Management: A Contemporary
Perspective. Rockville, Maryland; An Aspen Publication, 1981.
[5] Graber TB. Structure and function of the emergency department: matching emergency department choices to the emergency department mission. Emerg Med Clin North Am. 2004;
22: 47-72.
[6] Ceylan S. Occupational satisfaction scale’s questions and
evaluation form. (Hacettepe University Literature Faculty
Department of Pschology Unpublished Working Study).
Ankara, 2010.
[10] Lara P, Zoghbi, MA, Rodriguez TFE. Organizational Anomie
As Moderator Of the Relationship Between Unfavorable attitudinal environment and Citizenship Behavior (ocb) An
Empirical Study Among University Administartion And
Services Personel. Personel Review, 2007; 36: 843-66.
[11] Irvine D. Cognitive and Behavioral Outcomes of Quality
Improvement Teams: The Influence of Leadership and the
Work Unit Environment. Journal of Quality Management,
2000; 4: 167-184.
[12] Bernburg JG. Anomie, Social Change And Crime, A
Theoretical Examination Of Institutional Anomie Theory.
British Journal Of Criminology, 2002; 42: 729-42.
[7] Seoa Y. The Determinants of Job Satisfaction among Hospital
Nurses: A Model Estimation in Korea. International Journal of
Nursing Studies, 2004; 41: 437–46.
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© 2013 Acta Medica. All rights reserved.