Nurses ’ Work Environment Characteristics and Job Satisfaction : Evidence from Georgia

Introduction: The health care system and health care service delivery is essentially dependent on the number of medical staff working in the network, their level of education, work environment and job satisfaction. There is a shortage of nurses’ in Georgia, which has an adverse effect on the health care system and patient care outcomes. The aim of this study is to measure the work environment characteristics, job satisfaction and to evaluate the association between these variables. Methods: The quantitative research method was used. The Work Environment Scale and a Job Satisfaction Questionnaire were administered. Descriptive statistics were used to describe the sample and results of the questionnaires. Results: The majority of nurse’s reported lower levels of job satisfaction, work environment characteristics. Discussion: The nurse shortage is caused by a variety of reasons, including the inability of the health care system to keep nurses in a workplace. Due to the economic situation, nurses' annual salary is very low. The hospitals are trying to reduce the number of nurses or not to hire additional nurses due to economic reasons. Nurses have less will to work with the existing working conditions. Policy makers should address many issues: improving recruitment, retention and return in order to keep or increase already few number of nurses. The development of programs to improve the nurse practice environment, especially staffing and resources, could improve nurse retention and thereby slow down the nursing shortage.


INTRODUCTION
According to the World Health Organization, "The main goal of public health staff policy is to prepare appropriately qualified personal" (1).After the downfall of the Soviet system, independent Georgia inherited the excess medical infrastructure, large pool of beds and medical staff (2,3).Georgia has one of the highest numbers of doctors per person in Europe.According to 2012 statistics, there are 4.8 doctors on 1000 capita (5).However, the number of nurses is very low and decreases every year (5).As a result, there is a serious shortage of nurses in Georgia.According to statistics, nowadays 13,000 nurses are employed in Georgia.According to the experts, in order to increase the quality of healthcare, it is necessary to increase this figure up to 30,000 and to achieve the European level the country has to prepare 1,400 nurses per year (6).
One of the most important indicators of quality of medical services is the nurses/doctors ratio.The recommended ratio by World Health Organization is 3/1; In Georgia, this ratio is 1/0.9 and stands in last place in Europe (5).This problem is a serious threat for the proper functioning of the healthcare system, for its cost-effectiveness and sustainability (5).Another major problem is an unequal geographical distribution of nurses in the country.
Reduction of the number of nurses in the country is significantly affected by the low salaries.The government does not regulate the salaries of nurses and it mostly depends on the goodwill of the medical facilities.Generally, nurses' monthly salary is less than 250 GEL ($100).It should be noted that, in recent years the salary in rural regions was increased from 350 GEL to 455 GEL ($180).According to the experts, a low salary for nurses in Georgia is caused by their low qualification, which in turn is caused by the fact, that there are no nursery training courses in country (6).According to the official statistics in Georgia, only 100 nurses graduate from the university annually, while the average number provided by the European standards should be 1400 graduate a year (4).Another serious problem is the aging process.The average age of highly qualified doctors and nurses who gained there education and vast experience during Soviet period is already above 50, and the deficit is expected to hit Georgian healthcare system in the coming years (5).During 2007-2011, the donor organizations sponsored the training program, which produced 1934 trained nurses for primary healthcare; but it was only 80% of what was needed (4).
Nurses are the main professional components of the 'front line' staff in most health systems, and their contribution is recognized as essential to meeting development goals and delivering safe and effective care (7).The shortage of nurses is an international problem, especially in countries with a low and average income.This has a negative effect on the healthcare system and on patient care outcomes (7)(8)(9)(10).A range of studies have demonstrated links between a nurse staffing levels and a range of negative health outcomes (11).These include an increased mortality rates (12); adverse events after surgery (13); and increased cross infection rates (14).The OECD has noted, that 'Nursing shortages are an important policy concern, because numerous studies have found an correlation between a higher nurse staffing ratios and reduced patient mortality, lower rates of medical complications and other desired outcomes.'(15).
The shortage of nurses has a variety of reasons.The studies focusing on nursing shortages in developed countries have highlighted the main causes of these shortages as: an inadequate workforce planning and allocation mechanisms, resource-constrained undersupply of a new staff, poor recruitment, retention, and ineffective use of available nursing resources through inappropriate skill utilisation, poor incentive mechanisms and inadequate career support (16).
Other factors contributing to nursing shortages, which require policy attention, include: the healthcare system's inability to keep nurses in a workplace (17).The current working conditions are very unattractive for nurses, and therefore majority of them are not willing to work under those conditions (18).The working environment is an important factor in terms of their on-site restriction and job satisfaction (19).When there is already a deficit of nurses (20), then such issues become very important, because those, who work in medical facilities with negative environmental conditions, are not satisfied with their jobs and the probability of leaving work increases.The environment of working area is defined as the organizational characteristics of working environment that facilitate or impede the professional nursing practice (21).
Nurse retention is also a problem in many counties (22).Their intention to leave job ranges between 13.5-67.5% in the world (23).For example, in USA, 8.5-14% of nursing jobs are vacant.At the same time, this rate is higher for emergency (resuscitation) medical service departments (24).According to the studies, there is a significant negative correlation between the work environment and nurses' intention to leave (25).
According to the studies, nurse's job satisfaction is correlated with good working conditions and good organizational environment (26).Job satisfaction significantly affects the retention of nurses in the workplace (27).According to the studies, nurses who had higher workload, also were less satisfied by their jobs (28).According to several studies, there is a correlation between nursing work environment and nurse's job satisfaction.
The aim of our study is to find out and discuss the correlation between nurses' work environment, nurses' retention and their satisfaction with working place in Georgia.In this way, it will be possible to identify the problems that require solution.

METHODS
The methodological basis of this research is the available literature about nursing activities.The method of quantitative research was used.Three large hospitals of Tbilisi were selected for research.All of the registered nurses who worked on these hospitals were asked to participate.
The following Demographic and professional characteristics were measured: age, sex, marital status, current nursing role (head nurse, unit's head nurse, nurse), employment status (full time, part time).
Practice Environment Scale (PES) was developed to measure the nurse practice environment (21).Responses were in the range from 1 (strongly disagree) to 4 (strongly agree).The questionnaire was based on the Nursing Work Index (NWI) and the Nursing Work Index was revised to measure the hospital characteristics (29,30).After completing a factor analysis of the NWI data, the PES was developed, which comprised of 5 characteristics: nurse participation in hospital affairs; nursing foundations for quality of care; nurse managerial skills, leadership, and support of nurses; staffing and resource adequacy; and collegial nurse-physician relations.Nurse retention was measured by the following question, " I have Intentions to leave the current workplace", measured on a scale from 1 (strongly disagree) to 4 (strongly agree) (31,32).
Job satisfaction was measured was measured using a single question that measures overall job satisfaction, "How happy you are with your working place?" measured on a range from 0 to 5.
The questionnaires were left in hospital's staff mailboxes.Questionnaires were returned in sealed envelopes to a central location on the unit.The data were anonymous.Descriptive statistics were used to describe the sample and the results of the questionnaires.

RESULTS
The majority of the respondents were women (n=100, 100%).Most respondents (38%) were 40-49 years old.Majority of the total respondents were married women (45%), single women were third of the total number (32%), the majority of nurses were full time workers (68%) (Table 1).According to table 2, the majority of nurses (56%) believe that they do not have the opportunity to fully develop their nursing careers and reach the clinical perfection and most of them (63%) think that they do not have the opportunity to take part in the hospital's policy decisions.There are almost equal number of respondents who believe (49%) or do not believe (51%), that chief nurse is a very important and visible staff member.60% of respondents do not believe that the nurse has the same powers as other high-level executive staff of the hospital.70% of respondents do not believe that there are some opportunities for nurses to advance at the hospital.55% of respondents believe that the administration always listens and responds to employees' problems and concerns.69% of respondents believe that nurses are not involved in the internal governance of the hospital (for example -participation in committees working, policy making).66% of respondents believe that the nurses do not have the opportunity to work in a hospital's committees.
According to table 3, the most respondents (64%) believe that the hospital is trying to develop educational programs for nurses.Most respondents (77%) believe that the administration expects high standards from the nursing activities.Most respondents (70%) believe that in the hospital, it is not recognized the concept of nursing and patient care environment is not imbued by this concept.Most respondents (60%) believe that they are working between on skillful and competent nurses.Most respondents (66%) believe that there are a quite quality assurance programs in hospital.Most respondents (55%) believe that there are special programs for newly hired workers.According to table 4, 34% of respondents think that the hospital managers are always trying to be supportive towards them.Most respondents (71%) believe that the head nurse is also a good manager and a good leader.
Most respondents (56%) believe that a good performance is always followed by praise and recognition.Most respondents (72%) believe that the head nurse supports nursing staff's decisions, even if it will lead to a conflict with doctors.According to table 5, the most respondents (63%) believe that they have the favorable conditions to spend appropriate time with their patients.Most respondents (54%) believe that there is enough time and opportunity to discuss patients care problems with other nurses.
Most respondents (66%) do not believe that there are enough nurses to conduct high-quality medical services.Most respondents (73%) do not believe that there are enough personnel for work.According to table 6, The most respondents (73%) believe that doctors and nurses have good working relationships with each other.56% of respondents believe that the nurses and doctors are working as a team.
Also, the majority of respondents (56%) believe that the doctors and nurses have the good cooperation between each other (Collaborative practice).

DISCUSSION
As the study shows, nurse job satisfaction is The most significant and lowest rated characteristic of the nursing practice environment was 'appropriate staffing and resources'.However, these results were not unexpected, according to the fact that in emergency departments of hospitals, the bed occupancy rate is relatively high.The problem becomes further compounded if we consider the significant decrease in the amount of nurses.The level of intention to leave the job turned out to be significant (38%).For comparison, on the international level, the level of intention to leave the job by nurses range from 13.5-67.5% (23,33).
Due to the economic situation, nurses' level of compensation is low.The hospitals are trying to reduce the number of nurses or not to hire new nurses due to the economic reasons.The nurses deficit increases the workload.Today, the number of patients per nurse in Georgia exceeds all standard and recommended norms.Due to a small salaries, nurses are forced to work in several places.Currently there is no state standard for how many patients should a nurse serve.Accordingly, because of low salaries and hard work, the nursing profession is not attractive and prestigious.The number of nurses decreases annually.This is partly due to the fact that a nurse working conditions (and patient-nurse ratio, salary) in Georgia is only determined on medical facility's level and Ministry of Health and the Nurses Association does not participate in this process.There are significant differences between hospitals in salaries.Therefore, to improve working conditions it is most likely that nurses will change their place of work.
Policy makers should address supply side issues: improving recruitment, retention and return-getting, keeping with these relatively scarce nurses.Factors related to work environment can be crucial, and there is some evidence that decentralized style of management, flexible employment opportunities, participation in decision making, access to continuing professional development, Proper compensation can improve the retention of nursing staff.

CONCLUSION
Given the fact that the nursing shortage is a health system problem, which undermines health system effectiveness, policy makers should acknowledge and try to improve those practice environment characteristics that were shown to be related to nurse job satisfaction and intent to leave.Special attention should be paid to staffing and resource allocation in larger hospitals.The development of programs to improve the nurse practice environment, especially staffing and resources, could improve nurse retention and thereby slow down the nursing shortage.The state should facilitate professional growth of nurses.Without training on modern standards of nurses, it is impossible to further develop the health system.It is necessary to raise the motivation of nurses, their activity and their interest in training courses.

Table 3 .
Nurses contribution in respect of to the quality of medical services (%)

Table 4 .
Nurse Manager Ability, leadership, and support of nurses (%)

Table 7 .
Nurses job retention (%)According to table 8, the majority of nurses' job satisfaction level is low 8).On the question, "To what extent are you happy with your place of employment?" most of the respondents measured 3 points (40%).