Analysing the prevailing status of nurses at private hospitals in Bangladesh: A study on quality of work life

Enhancing the quality of the work of employees and the overall productivity of an organization are considered the basic premises of Quality of Work Life (QWL). The purpose of this study is to examine the prevailing status of the level of QWL of Nurses at private hospitals in Bangladesh, to identify the critical factors influencing the QWL, and to suggest some strategies to improve the QWL. This study follows a mixed method approach to collect and analyze the data. This study reveals in terms of QWL of Nurses at private hospitals in Bangladesh that the nurses are suffering from considerable discrepancies in the working environment, job security, payment structure, promotion policy, overtime and shifting, and pressure on the job. Based on the findings, this study suggests some strategies for the concerned authorities to mitigate the sufferings of the nurses at private hospitals and ensure the QWL on it. *Correspondence to: Kingsley Emwinyore Agho, Department of Biostatistics, School of Science and Health, Western Sydney University, Australia, E-mail: K.Agho@westernsydney.edu.au


Introduction
National health care policy in Bangladesh is trying to ensure the high quality, affordable medical facilities to all the citizens through private and public hospitals. Consequently, the Government of Bangladesh has established numerous public hospitals in rural and urban areas. Similarly, a great number of private hospitals have also been established in both settings. In Bangladesh, the number of people increased that does not match the number of hospital beds, and a great number of physicians and non-physician staff such as nurses are needed to meet health care demands. For every 1,000 people, there are 0.3 nurses and midwives. This statistic shows the extreme lack of nurses and midwives in the country. Overall, the country lacks a strong health workforce, as there are only 0.58 health workers for every 1,000 people in the country [1]. To provide better health care, the contribution of the nurse is well recognized. They are interdependent, private and public hospitals practising in partnership with physicians, and are found in almost every medical and surgical speciality. This medical speciality developed to manage the shortage of physicians and to ensure that patients receive high-quality health care in what has become an increasingly complex medical environment.
Nurses work in a diverse array of medical environments, from hospitals to private practice to outpatient facilities [2], and several studies have shown that the care they provide is somewhat equal to that provided by physicians [3,4]. Evidence shows that after getting a prescription from a physician or after surgical operation, the assistance from nurses is essential for quick recovery from diseases. There is evidence that nurses are and will continue to become a significant provider of health care in all countries in the world [5,6]. Nurses are trained and certified to perform a variety of tasks that are meant to complement the work of other health care professionals. In Bangladesh, nurses perform duties that have traditionally been assigned to hospitals or clinics, including making rounds, change order by physicians, changing wound dressings, and educating patients about care and conditions, compiling medical records (e.g., progress notes, admission and discharge notes), assisting physicians during examinations (ordering laboratory examinations, help physicians on prescriptions, performing and reading the results of routine examinations) and operations (scheduling surgery, assisting during surgery, providing preoperative and postoperative care).
The roles and responsibilities of nurses, as well as the quality of work life (QWL), are related to attitudes and acceptance of the supervising physician and hiring authority, and the authority's willingness to provide the necessary equipment's [7]. Several studies have found that nurses are generally satisfied with most aspects of their jobs but their role in many health care systems is often ambiguous [5,6,8]. Although many factors influence the quality of work life, national laws, demographic variables, family life and internal policies of the organization are powerful forces outlining the boundaries. In Bangladesh, there is no specific legislation defining the responsibilities and liabilities of nurses. Most of the nurses are female, many of whom continue to work in the same environment with the same coworkers, and often have difficulty making the transition to their new role not only due to lack of training but also due to confusion. Good communication and a strong working relationship between the nurses and the supervising physician or other nonphysician staff (e.g. administrative personnel, pharmacists, doctor's assistants, and medical technicians) increase the level of job satisfaction and the quality of work life [5,7,8]. A number of studies have explored education of employees influence the level of QWL. They explained that both positive and negative phenomenon of the factors, age and sex had negative influence but experience and level of education had positive influence i.e. when the experience of the employee was higher, level of QWL was higher and as the same result was reported for the level of education. The study; DeNishi, and Griffin [11], found a positive relationship between age and QWL, no relationship between sex and QWL. They also found the positive relationship between service tenure and QWL, but they found no relationship between the level of income and QWL.
In recent years work-related factors and QWL are the two important issues in human resource management researches. It appears that lower QWL first manifests the employee by increasing job dissatisfaction, which may lead to an increase in quitting intent (or an increase in absenteeism). Naturally, it can be said that higher QWL leads to job satisfaction, coherent the employees in work for a long time [2,13,14]. Vega et al. [17] found in their study that communication, inducement and involvement influence employees' work satisfaction. And satisfaction can be reduced by communication competence, physical and administrative dispositions, absence of recognition and the stress in performance evacuation control. The satisfaction level is measured by economic rewards. As human being's perception, feeling, emotion, taste etc. are different from others and as they are changing, the nature of the relation between works related factors and QWL is complex. As a result, different kinds of literature show different results. For example, some scholars show in their study, male employees are enjoying more quality in work life than women, on the other hand, some scholars find no significant differences between men's and women's level of QWL. Some researchers found in their study; aged persons were more stressful than younger. Some researchers showed completely different result i.e. younger persons are more stressful than an aged person. Some showed a negative relationship between the level of income and QWL and some researchers depicted no relationship between QWL and level of income. But most of the researchers [4,7,8] acknowledge that long-lasting low QWL leads to extreme job dissatisfaction by which the employee feels the organization growth is worthless in the context of his/her own interest, employees try to run away from the organization and they do not try to the development of the organization.

Methodology
This study follows both qualitative and quantitative research methodology. In this regard, this study considers both primary and secondary data source. The primary data has been collected through indepth interviews, FGDs and quantitative questionnaire survey. While conducting FGDs the data collector faced two challenges; firstly, the nurses were found in rush to maintain their rosters; they hardly can manage time to talk; and Secondly, in hospitals the group could not be easily formed as they have to stand by patients all the time and these nurses usually have little time outside hospitals to share their words in a convenient way. Despite such hurdles, two FGDs have been conducted in two different hospitals. On the other hand, the secondary data has been collected from various published materials such as WHO's report, journal articles in this field, report of Bangladesh Bureau of Statistics and Ministry of Health and Family Welfare, Bangladesh.
All nurses working in private hospitals in the rural and urban areas of Bangladesh constitute the population of this research. According to Directorate of Nursing Services [18], as of January 2011, Bangladesh had 26644 registered nurses, among them 66% employed in public health sector, 23% in private sector and the rest, 11% employed in QWL among nurses; the majority comes from hospital-based research in western countries [4,9]. However, it is needed to understand the perspective of developing counties like Bangladesh.
Organizational relations denote a highly complex and dynamic process of the relationship involving the workers and the management as well as their collective forums and the state. The absence of turnover does not mean that the complete quality of working life prevails in the organization [10,11]. The work-related discontent along with demographic variables influence the quality of working life. WHO [1] found that nurses are in deplorable condition especially in the private sector due to not having a standard guideline for duties. Deplorable socio-economic conditions degrade the quality of hospital employees in developing countries causing discontentment and degrade the quality of services [11]. Usually, workplace violence and aggression are also growing concerns in many organizations but in hospital violence among employees are rarely found in a hospital, they keep their discontentment in the heart rather than disclosure publicly. In this sense, what is the importance of studying QWL? It has been argued that QWL influences the performance and commitment of employees in various organizations, including health care organization. A high QWL is essential to attract new employees and retain the workforce for a long time. Consequently, health organizations are seeking ways to address issues of recruitment and retention by achieving a high QWL.
In countries like Bangladesh, factors that influence QWL are multidimensional and include individual as well as work-environmentlevel factors. Individual-level factors included age, sex, working tenure, experience, and job interest. Work environment-level factors include working conditions, job security, welfare measures, supervision. However, to date, QWL has not been a priority and data to inform policies are lacking. The purpose of this study are to examine the prevailing status of the level of QWL of Nurses at private hospitals in Bangladesh, to identify the critical factors influencing the QWL of Nurses at private hospitals in Bangladesh, and to suggest for employers some strategies to improve the QWL of Nurses at private hospitals in Bangladesh

Literature review
Quality of work life is a complex entity influenced by, and interacting with, many aspects of and personal life [12]. Brooks [13] argued that QWL has two goals; improving the quality of the work experience of employees and simultaneously improving the overall productivity of the organization. From the nursing perspective, Brooks defined the QWL as "the degree to which registered nurses are able to satisfy important personal needs through their experiences in their work organization while achieving the organization's goal. " Therefore, the concept of employee satisfaction is about more than simply providing people with a job and a salary. It is about providing people with a place where they feel accepted, wanted and appreciated [4,14]. Quality of work life means changing the entire organizational climate by humanizing work, individualizing the organization and changing the structural and managerial system. It seeks to create a culture of work commitment in the organization which will ensure higher productivity for the company and greater job satisfaction for the employees. High job performance is not possible unless and until employees get better quality of work life [15]. Quality of life is a term integrating several aspects such as physical, psychological, social, economic and emotional dimensions. The disturbance in any one of these aspects will, in turn, affect QOL significantly [16]. The study conducted by Almalki et al. [4,9] found that some demographic factors such as age, sex, experience and level of abroad. The nurses working in public hospitals and abroad would be considered as the population of this study. Thus, the nurses working in private hospitals operating in Dhaka, Bangladesh was the sampling unit of this study. However, by using the stratified random sampling technique this study conducted the survey on a total of 175 nurses (senior staff nurse, assistant nurse and aide).

Result and discussion
Socio-demographic distribution of the respondents Table 1 shows the socio-demographic status of the respondents of this study, it shows that the majority (46.9%) of the respondents were in age ≤ 25 years old. The mean age of the respondents from the public hospital was 1.85 ± 0.961 years. Most of the respondents (86.9%) were female and the rest were male. The majority (78.3%) of the respondents was married and the rest were unmarried. More than half (61.1%) of the respondents had a diploma in nursing, followed by B.Sc. in nursing (16.6%) and the rest had a combination of diploma and nursing level of education. 51.40 % of them are pursuit on the field for less than 5 years.

Quality of work life of nurses
The respondents are satisfied with their overall working environment; whereas they said that they have insufficient break area (room for rest, eat and pry) (56.00%) ( Table 1). Furthermore, they were much concerned about job security. Findings show that they are not satisfied with their payment structure, although a large number of respondents remained neutral (46.30%) about their payment structure ( Table 2). In the context of promotion policy, they have shown the same response as what they expressed about their payment structure. There is also a large number of respondents (37.10%) even-handed with their promotion policy (Table 3). In this study, respondents have a good relationship with their colleagues. Although the study shows that respondents felt their overtime and shifting is acceptable, but there is a great portion of respondents (30.90%) are also unaffiliated with their overtime and shifting (Table 4). Following such kind of mixed responses, participants also expressed farraginous attitudes towards the pressure on the job. However, they said they have no health concerns about their jobs.
Case study: poor salary structure and workload ' Amema' (pseudonym) one of the outspoken participants working in a private hospital. She was focused and uttered specific experiences which she has gathered in her working zone. She was absolutely stressed about her workloads and at the same time, she was totally dissatisfied about her salary. According to her, it was hard to run her life with such a minimum amount of money which she received a salary from the hospital. In the same time, heavy workload made her life quite depressing as she could hardly manage any time for her family and especially for her kids. She thought that her tight and disorganized roster, designed by the hospital, let her do the job always in a rush. She rarely made contact with the persons holding superior positions to her. Hence, the issues which she had faced during her working period and the rights that she had wanted to claim rarely shared with the related authorities. She added that she was not clear about the salary and work schedule. However, she told that she had not faced any problems while dealing with patients. Above case study shows that even the two important factors as the relationship with co-workers and dealing with patients remained positive to this nurse, huge workload due to the disorganized roster, dissatisfaction regarding salary, lacking in a proper communication system with the authorities and obscurity in promotion policy results in an unhealthy work environment for her.

Case study: job security
'Bandhan' (pseudonym) had been enrolled in a hospital as a nurse for three years. She told that she felt newly employed even after three years of joining the hospital and she had nothing to say about hospital management. At first, she was inarticulate about sharing anything about her working life in the hospital. Gradually, in a friendlier environment, she shared the fact that the workload which she had to bear was making her life miserable. Whereas, the salary she received from the hospital did not bring any satisfaction in her life. She had to live with her family from hand to mouth. However, she had a no better option to choose except this hospital as a scenario were quite the same in the nursing profession, she opined. Hence, she did not want to lose this job and she scared that she might not find any other job even holding the diploma in nursing. (Source: B. Akhter, personal communication, March 13, 2019) It is noteworthy from this case study that despite having salary discrepancy and other irregularities in hospital management the nurses rarely have anything to say, the hidden reasons behind the scenario is lack of job security. The authority at any time, with no proper justification, can quit the nurses from the job. This study also found miss management in promotion of the nurses. Some of the FGD participant blamed on the roster system, others pointed on the management authority. One of the participants stated that "… the authority of hospital management is reluctant to employ required nurses according to the increasing demands in the hospital; rather they are imposing extra work on the currently working nurses, and even doing more work does not take any means in promotion or salary increase…". It was noticed that the internal promotion policy in a hospital is much complicated and the nurses have less expectation for achieving their desired promotions and increment in their salary. However, the nurses express their satisfaction over their colleague as because they can get support from each other. In some private hospitals, the participants claimed that the congested place of the hospital is troubling them to work in a solitary manner. In such a small place, nurses have to manage to provide required services to the patients admitted into the hospital. Thus, the profit-seeking mentality from private hospitals often hinders the natural movement of the nurses.

Discussion
Unlike the mixed findings under quantitative data collection procedure, according to the two case studies and two FGDs as qualitative data collection methods, it is mostly found that there were the unhealthy working conditions and it can be assessed with the correlation between fear of being laid off and dissatisfaction about monetary gaining and heavy workload in different hospitals. First and foremost, the indicator, 'fear of being laid off ' is quite obvious in a sense that it made the nurses feel unsecured about their jobs. For instance, the second case study reveals the fact that why participants were reluctant to share their actual experiences. It can be assumed from an in-depth interview, conducted for developing this case study that the fear of being laid off remained active so strongly. Following the same tendency or fearfulness, it can be possible that more participants during the quantitative data collection process remained neutral or agreed on those issues that they did not want to share. Moreover, in a quantitative study, a significant percentage of the participants admitted that they are afraid of being laid off and 58 per cent of nurses strongly agreed on this issue. Adding to this, 53 per cent of the participants strongly agreed that their tenure is unsecured. Such variables indicate the working condition where the nurses can hardly exercise their work-related rights or remain silent to hold down their jobs. Furthermore, it can be assumed that this fearfulness among nurses of losing their job let them accept all dissatisfactions regarding their current jobs at hospitals. For instance, almost every participant in qualitative data collection period shared that they were overloaded with their works, whereas in the quantitative study it is found that 26 per cent of the participants remained neutral on this issue.
In terms of salary, all qualitative participants used the dissatisfactory terms and almost all of them told that they got an inadequate salary against their heavy workload. Quantitative data also revealed much dissatisfaction among nurses on their monetary gaining from the hospitals. Around 70 per cent strongly agreed that they are not satisfied with their salary. Adding to this, in case of temporary incapability of working, more than half of the participants (56% strongly agreed on this issue) were sure that their payment will be discontinued. While one case study finding depicts participant had less communication with the person holding the superior positions, in a quantitative data collection period, more than half of the participants (55.4%) shared that they did not find it troublesome to talk to their boss. On the other hand, around half of the participants (45.7%) accepted that they are unable to predict their supervisor's reactions.
From the qualitative study, it is mostly found that the promotion policy is either not clarified to the nurses properly or the policy is following much rigidity, therefore, almost all of the nurses who participated in qualitative data collection procedure have claimed the policy is complicated for them. Moreover, some of the participants stated it clearly that they have less expectation for the promotions or increment by such policies. Quantitative data also showed such findings to some extent in its percentage explanations. Around one-third (32.6%) of the participants of the quantitative study identified unfair promotion policy and around half of the participants (42.9%) strongly agreed that there is limited opportunity to get a promotion. Such findings are indicating the presence of ambiguity regarding promotion policies and the less accountability which is maintained for nurses by the hospitals.

Conclusion and recommendations
After having all the discussion, it can be concluded that the quantitative findings show a non-significant effect on Quality of Work Life of nurses in private hospitals of Bangladesh. Only nine per cent of the total variations in work-related factors has found which impacted on the dependent variable of the study and resulted into the fact that 'Organization does not provide independent and healthy work environment' . However, being focused on the study hypothesis, qualitative data indicates that the independent variables like payment (settled for the nurses), relation with peer and relation with the senior authorities, job design, job security, recruitment and promotion policies have significant effects on QWL of nurses which is the dependent variable of the study. This study will help to understand the influence of various factors on QWL in the service sector i.e. the nurses of private hospitals in Bangladesh. This is a tentative study and will be revised and corrected in the light of further study in consultation with related academician(s). However, the findings of the study merit some recommendations as follows: • The private hospitals need to maintain the former contract of appointment and clarify it to the nurses. There should not be any clause written in a complicated manner, which ultimately makes nurses unaware or unable to understand the hospital policies. Especially, the promotion policy should be clarified to the nurse that they can proceed under the policy without any vagueness.
• The roster should be organized in a way that any rush should not occur among nurses who are on duty. Hospital employers should consider hiring more nurses to meet the demands of nursing services. In this regards the authority in Bangladesh needs to ensure quality nursing education services and training for the hospitals.
It is evident from this study that poor salary structure is one of the main causes behind the dissatisfaction among nurses and such discontent is ultimately creating the unhealthy work environment as well as sufferings in the personal lives of the nurses. Therefore, employers should concentrate on increasing the salary of nurses considering their valuable responsibilities in hospitals. Most importantly, the government should take the immediate policy to ensure the adequate salary for the nurses in any hospital of the country because they make significant contributions towards the health sector of the country.
The fear of being laid off indicates the non-friendly working environment for the nurses in the hospitals. Therefore, the code of conduct must be taken and followed by every hospital. A strong monitoring system should be applied in hospitals where personnel holding superior positions also should be observed and their behaviours towards the nurses should be monitored. For this purpose, the accountability system should not be imposed only for the nurses but also for the authorities who should be accountable to the nurses in their work-related issues and policies.
Internal promotion policies should be clarified to all working nurses in every hospital. Moreover, the policy should be included with such initiatives that motivate nurses continuously to complete their works more efficiently.