Evaluation of job satisfaction of employees of a public hospital care recognized effectiveness

Objective: To evaluate job satisfaction of non-medical professionals in order to identify potential service failures and propose changes for improvements. Methods: A cross-sectional, descriptive study of 14 employees in the Ophthalmologic Center Divinolândia Regional Hospital in São Paulo state. Was used as a research tool, a self-administered questionnaire developed by the authors. The collected data were tabulated and presented in tables. Results: Reported great satisfaction with the work performed (71,4%). The factor that most pleased the employees in the workplace was the good relationship with colleagues (35.6 %). Considered as great the relationship with the medical staff and the patients (71,4%). Mentioned as the most unpleasant factor in the workplace, the fact that the physical space is very small (35.7%). Most employees (64.3 %) worked in the institution for more than 10 years. Conclusion: We found a high satisfactory degree of employee satisfaction with the institution, with medical staff and patients.


INTRODUCTION
For a long time, work used to be associated with sacrifice.The notion of work as a means of self-actualisation emerged during the Renaissance 1 , when work came to be seen as an opportunity for creation, achievement and personal growth, enabling man to leave an imprint on the world 2 .
Work should be integrated with life and should have a meaning; it cannot be merely a means of survival.In order to carry out plans and projects at work, individuals need to nurture good relationships.In the health sector, this includes not only peers but also the medical staff and patients, which helps improve the quality of care. 2 In public health institutions, especially in developing countries, identification with and commitment to work is particularly important, as the people who use these services generally have a low income, poor education, difficult access to health care, and are vulnerable due to their health condition 1 .This is the reality in the Eye Clinic of Divinolândia Regional Hospital (Conderg), which collaborates with the Department of Ophthalmology of the University of Campinas (UNICAMP) to provide free medical and surgical care for users of the Brazilian public health service (SUS) coming from 16 cities of the São João da Boa Vista region (490,000 inhabitants). 4he Divinolândia Eye Clinic has been previously evaluated.In 2011 it was regarded by users as one of the best public health services in the State of São Paulo, and in 2006 health managers and patients rated its medical and nursing care as excellent. 5][8] In this context, is believed that an environment in which health care providers (administrative, support and medical staff) feel satisfied with their working conditions, are motivated and find meaning in their work can contribute positively to successful acceptance of and adherence to treatment 4 .
The aim of this study was to assess the job satisfaction of non-medical staff at the Eye Clinic of a public hospital in order to identify potential problems and suggest measures to improve patient care.

METHODS
A cross-sectional descriptive study was conducted at the Prof.Dr. Newton Kara-José Eye Clinic of the Divinolândia Regional Hospital, Divinolândia/SP, Brazil.
The sample consisted of 14 nursing and administrative staff who agreed to participate in the study and provided their free and informed consent.
The research instrument was a self-administered questionnaire developed by the authors with closed-ended multiple-choice questions which aimed to estimate the level of satisfaction with the workplace, colleagues and medical staff.
Data were collected from June 14 to 18, 2010.Participants were not identified and were neither coerced nor forced to answer all questions.
Results were entered into a database and answers were tabulated.The arithmetic mean for each group of questions provided a corresponding index for each dimension.

RESULTS
Most employees (64.3%) had worked at the Prof.Dr. Newton Kara-José Eye Clinic of the Divinolândia Regional Hospital for over 10 years (Table 1), and for 42.8% this was their first job.
All respondents reported good or excellent levels of satisfaction with the work performed at the Eye Clinic (Table 2).
When asked about the most pleasing aspects of the work environment, the good relationship between staff members was the most frequent answer (Table 3).
As for the negative aspects of the work environment, the physical working space was the most cited (Table 4).
All staff members reported having a good or excellent relationship with patients at the Eye Clinic (Table 5).
Regarding their concern for the well-being of patients, all employees stated that they empathised with patients (Table 6).
All participants reported having a good or excellent relationship with the medical staff (Table 7).
All participants rated the services provided by the Eye Clinic as excellent and would recommend the hospital to family and friends (Table 8).

DISCUSSION
The golden age of self-actualisation through work was that of craft production, when workers took part on all stages of production and were greatly identified with its end result.After the industrial revolution, with consumers increasingly accepting undifferentiated mass-produced goods, emotions left the workplace.
A work schedule was established, predetermined times were set for each task, and the free time and leisure activities of workers started to be controlled to prevent them from interfering with their mood for work.In the 1980s, many companies expanded to different parts of the world by outsourcing or subcontracting their activities.It was the phase of flexible capitalism, when permanent jobs disappeared and work became more precarious and unstable (2) .
Although work is the centre of most people's lives, a growing number of workers do not recognise the professional sphere as a space for actualisation where they can feel valued and useful to society.Furthermore, even though a minority of workers feel involved and identified with the activities they perform, a large group of people work only due to their financial needs and would easily change jobs.For them, work is not an end in itself, but only a means to achieve other goals (2,9,10) .
Frederick Herzberg developed a theory that identifies the consequences of certain types of events in a worker's life in an attempt to determine which factors lead him/her to feel satisfied or dissatisfied at work.The author concluded that job satisfaction and dissatisfaction arise from two sets of factors.On the one hand there are extrinsic factors, which include working conditions such as salary, type of leadership or supervision, physical and environmental factors, company policies and guidelines, the relationship between the company and its employees, and internal regulations, among others.However, even when extrinsic factors are excellent, they only avoid dissatisfaction.
On the other hand, intrinsic (motivational) factors are associated with the content of a position, the nature of tasks to Machado MC, Silvestre RC, Kara-José N, Kara-Júnior N Rev Bras Oftalmol.2014; 73 (3): 143-7 be executed, and rewards for job performance.These motivational factors are under the individual's control, as they relate to how the worker perceives his/her activities.They involve feelings of personal growth, responsibility and professional recognition (11) .
The demands of consumers in the Brazilian health sector are changing, as they are no longer satisfied with simply being seen by a doctor.They also demand that the health care system be held accountable for the outcome of interventions, which implies providing appropriate counselling about health conditions, their management and prognosis and creating conditions for adherence to treatment.Health care facilities should offer the best possible services, and indicators are used to evaluate their performance, the services they provide and consumer satisfaction (12,13) .
Since the works of Donabedian in 1997 the international medical community began to recognise the importance of user satisfaction with the health care system (14) .It is now believed that information on worker motivation, work climate and organisational culture can help correct potential service gaps and failures in order to meet the organisation's internal and external demands and to ensure employee satisfaction by improving their quality of life at work (15) .
The quality of services provided by Conderg has been publicly recognised, as evidenced by the fact that the Divinolândia Hospital has received prestigious awards from the Brazilian Ministry of Health and the São Paulo State Health Office based on user evaluation (6) .Considering the importance of the Eye Clinic of Divinolândia Regional Hospital in promoting eye health in the São João da Boa Vista region, this study estimated job satisfaction among its staff.This is important because, according to Frederick Herzberg's theory, the mental health of workers can impact on the provision of services (11) .

Years
Among the employees of Divinolândia Regional Hospital, 64.5% had been working there for over 10 years, and for 42.8% this was their first job.Job stability favours identification with an institution's mission.According to Kramer et al. (16) , long job tenure enables the development of more solid and lasting relationships with the company, thus promoting mutual commitment and respect.
This assessment suggests that there is a spirit of solidarity among employees, who do not have serious disagreements and who form friendships outside the workplace.Furthermore, the entire staff is satisfied with the work performed in the institution and its outcomes.
Having a job does not guarantee professional and personal fulfilment.Work is never neutral; it either promotes the health of workers or helps to damage it (17) .Therefore, work organisation and worker management influence the way individuals work and behave, affecting them physically and psychologically (18) .
For a third of participants in this study, a small physical space was the main cause for dissatisfaction.In his theory on job satisfaction, Herzberg stresses the importance of physical and environmental working conditions (11) .Recognising this issue was critical for the decision to build a new Eye Centre with an area of 1,100 square meters, which is already operational.
None of the respondents cited their pay as a reason for dissatisfaction, despite the financial limitations faced by public services.Herzberg regards salary as an extrinsic factor and stresses that intrinsic factors are the most critical for maintaining employee satisfaction (11) .
All employees considered good relationships, team spirit, self-satisfaction with their performance, easy access to their direct supervisors, and the consideration given to their suggestions for improving services as the main elements that make them feel valued by the institution.These factors create the conditions for a good relationship between workers and the organisation.
The service has a continuing education program, employees participate in ophthalmology and management congresses, and there are monthly staff meetings with senior managers.Knowing the level of worker satisfaction is essential for a company to ensure quality and productivity.Siqueira et al. believe that modern companies aiming for success need to value their human resources, which are their main assets.Companies are also becoming more aware of the need to invest in training and quality of life at work, since healthy, motivated and skilled workers are critical for success in a globalised world (19) .
This study showed that the staff maintained excellent relationships with patients and empathised with their suffering, resulting in more humane care.
At the Eye Clinic, the excellent relationship between employees and the medical staff is particularly important, as doctors work with a team of ophthalmic assistants during all stages of care.Assistants perform pre-consultation activities (taking the medical history, measuring visual acuity and noncontact intraocular pressure), participate in medical care (reviewing the medical history, performing refraction tests and other tests, assisting patients and writing down test results), and, after the consultation, reinforce the physician's recommendations and resolve the patient's or caregiver's doubts, consulting the physician again if necessary.Table 7 shows that the staff have an excellent relationship with doctors, which is essential for the effectiveness of care.They also regard the service as good and would recommend it to family and friends (Table 8).
The fact that participants reported feeling that they can help others through their work shows a commitment to the quality of care.Moreover, all employees considered that the institution provided good or very good services to the community.The reported reasons for job satisfaction (team spirit, good relationships and a healthy work environment) are consistent with those cited by Herzberg (11) in his classification of intrinsic factors.
Organisational characteristics influence individual behaviour and, in turn, are influenced by the way employees think and feel.This suggests that worker motivation can affect the quality of a service and, consequently, the way users perceive it (20) .
Our results showed a high level of satisfaction with different aspects of the service.The Prof. Dr. Newton Kara-José Eye Clinic has developed a functional model for continuous improvement aimed at total quality of care.Offering high-quality care to users of the Brazilian public health service as well as supplementary training for medical residents from UNICAMP requires that all stakeholders be satisfied, from municipal authorities and health officials to users, doctors, and the entire clinical and administrative staff (4) .Abraham Maslow's hierarchy of needs theory is one of the most well-known models for studying human behaviour.It states that once primitive needs are met (those relating to physiology and safety, such as food, shelter and protection) more complex needs take their place, including social proximity and relationships with others.At a higher level, individuals need to feel valued and recognised for what they do.Finally, each person has a need for self-actualisation, an inner feeling of fulfilling one's potential (21) .
Factors related to the level of satisfaction, relationships with colleagues, a healthy work environment, the effectiveness of individual and group work, and recognition by patients were all rated as good or excellent.
This 25-year experience represents a successful model for public health care services in Brazil.

CONCLUSION
Within the conditions of this study, the Eye Clinic developed a model of care for users of the Brazilian public health service that produced a high level of satisfaction among its staff.

Table 7 Relationship with medical staff Table 1 Length of service of employees Table 2 Level of satisfaction with the work performed at the Eye Clinic Table 3 Most pleasing factors of the work environment Table 4 Most displeasing aspects of the work environment Table 5 Relationship between staff and patients Table 6 Level of empathy with the difficulties and suffering experienced by patients Table 8 Willingness to recommend the service to family and friends
Evaluation of job satisfaction of employees of a public hospital care recognized effectiveness Rev Bras Oftalmol.2014; 73 (3): 143-7 Machado MC, Silvestre RC, Kara-José N, Kara-Júnior N Rev Bras Oftalmol.2014; 73 (3): 143-7