Health Science Journal

Key words

Labour relations, hospital, administration of human resources

Introduction

The good labour relations include the output fair and reliable treatment between the workers, in order the workers to be devotional in the hospital. Hospitals with good labour relations present a strategy of human resources that attributes high value in the workers as partakers. A healthy labour environment is characterized by reciprocal respect and collaboration of various branches of workers and recognition. Essential condition for the excellent labour relations is the attachment in the “philosophy of respect of individual”. The managers will be supposed to hear, to understand and to keep their workers aware with regard to the drawings of administration as long as it concerns the organisation.

Conflict is the situation in which the behavior of a person or a team deliberately seeks to prevent objectives’ achievement of another individual or a team. It is an undesirable phenomenon that leads to negative results. Nevertheless, the conflicts in an organism are healthy and inevitable and can accompanied by positive consequences. The conflict can be constructive and have catalytic effect in the new ideas, the progress, the positive changes and the growth. This conflicts can be interpersonal conflicts (between individuals), common conflicts (between teams), hierarchical conflicts (authoritarian management), functional conflicts - more frequent in the hospital, conflicts staff - linear executives, conflicts between formal and informal organisation. [1]

The conflicts’ reasons are questions of prestige and imposition, conditions of work-increase levels stresses, responsibilities’ refusal, entanglement in roles because of problematic determination of duties as well as the different levels of education, provocative behavior toward the leadership, discriminations, complicated organizational labour environment, lack of vital space and different collaborating professional teams. Also, the existence of stereotypes with regard to the nurses’ and doctors’ profession, the change of nurses’ role, the predominance of woman in the nurse’s profession and the differentiation in the academician and in professional development. Moreover, conflicts’ reasons are questions of the limited resources (lack of personnel, economic, material and technical resources), lack of organisation and problems of administration, mentality’s differences, place, and educational level in the various hierarchical rungs.

The quality of workers in a hospital, their enthusiasm, their satisfaction from the work that executes, their experience, the feeling of their fair treatment, the motives that are provided for them, all these influence the productivity and finally the viability of hospital. [2]

Labour environment in the hospital

A hospital is a place where are met three different “cultures”, the medicine, the nursing and the administrative culture. The culture of an organism is a total of ideas and behaviors. The existence of culture helps the workers to maintain the limits of the team in which they belong in the organism.

Medical culture

The medical culture in hospital traditionally is supported in the force and in the power. The doctors learn how not to show their sentiment even if this helps the patient. They are durable and also do not complain when they feel exhausted. As a rule they learn to work individualized in each patient and they are complicated when they have to work in teams. It is marked that the medical culture is not single but varies proportionally the doctor’s speciality and the hospitals. It exists an increasing tendency of medical education to practice the students in the communication, in the common work and in the main subjects of management. [3]

Nursing culture

Nursing traditionally is supported in the offer of services with respect in the heads and doctors. Nurses are organised in a military type of organisation. Of course, the role of nurses has been improved and has changed dramatically with the existence of academic studies and the transport of knowledge from the nurses in the doctors for subjects of care and treatment. A decisive role has also the fact that the 90% of nurses are women and this means that many times becouse of their familial obligations are unable to participate actively in the culture of hospital. However, nurses learn to be more initiated and receptive in common work.

Managerial or technocratic culture

For many people the management is not considered a profession, neither allocates the scientific background of doctors. The managers learn from the world around practicing their reactions and their reflexives daily. They are interested for the total picture and the situation of ill-consumer and accordingly the hospital and no individualized for each patient as the doctors do.

Patient’s Culture

The patients transport the different cultures that exist in the society, play decisive role in the configuration of labour environment in the hospital. Changes in the society cause chain reactions and in the hospital. As an example the 30% of patients are informed for the developments in the health via internet and the remainder sources of information, so that they are more exigent in the “consumption of health services. [3] Indubitably having access in the information, they have not always justified requirements for the care that they have to receive. [4]

Intersectorial conflicts in the hospital

Consequently the hospital is a place where is provided the services of health. The hospital is a place sentimentally charged from the side of the patients and its functionals. A common culture in the hospital benefits an organism or a team via the promotion of collaboration and efficiency, decreasing the uncertainty and increasing the confidence. Consequently are created more powerful cohesive bonds between the personnel, but because of the conditions are increased the probability of appearance of intersectorial conflicts, which we will attempt to interpret.

Labour relations between medical and administrative personnel

According to Zupko, [5] the doctors declare that they are dissatisfied and miserable in the hospital in a world that continuously changes. Even if the reasons vary a part of their malaise is owed in their relation with their manager/governor. This malaise reflects international tendencies that led to autonomy’s and sovereignty’s shrinkage of doctors in the hospital and specifically afterwards the reforms that happened. As an example in the national system of health in England (NHS) where the import of manager’s institution in 1984, the opening of internal market from 1991 and the import of methods’ evaluation of activity of health’s functionals as well as the control of economic activity in the hospital, created intensities between doctors and manager. The last two decades existed efforts of doctors’ entanglement in administrative activities (medical director or clinically directorial) without a satisfactory attendance. The young doctors present theirselves more willing to deal with management’s subjects. It‘s a fact that doctors that worked as a manager experienced labour stress and high levels of disappointment. [6] All these led to a reallocation of force in the hospital and a new culture “these and we”. [7]

Causes that contributes in the intensity between medical and administrative personnel.

The regularisation of medical knowledge strengthened the intensity between medical and administrative personnel. This happened via methods that allow the measurement of medical work for administrative aims. Metres like this have been used in a lot of countries included USA, United Kingdom, Germany, Australia and Holland as a basis for likely compensations of health’s institutes after charges of patients. This metres determine how the doctors will be supposed to attend their patients in the individualised level for each patient (eg medical protocols-clinical protocols, guidelines) and the course of patients into the system (eg determined “paths” ill-prescribed “patient” pathways, use of information of feedback-feedback utilization data). The managers and the nurses support the regularisation while the doctors are negative.

Moreover, there is more attention in economically subject in health services. The systematic control and the restriction of expenses for the benefit of health’s services from the doctors it limits the manager’s autonomy and the consequence is the tight economic management of resources. [8] Also the changes in the legislation that concerns the doctors. These changes intend to decrease the offer of doctors, as it happens in Germany, in France and in Italy, while other reforms intend to decrease the government monopoly of institutes, as it happens in the United Kingdom, in Belgium and in Spain. [9]

All these strengthened the role of administrative personnel and the institution of manager in the hospital, so that the doctors react negatively. In England exists a tendency to accuse each government because the managers are supposed to be named by the Minister of Health. Many times the doctors declare that the managers do not understand them and that they are isolated from the medical profession. In general exists a suspiciousness as long as it concerns the legality of entanglement of management in the clinical work.

In England important role plays the fact of short alternation of administrative personnel, the 22% of managers changed in three years and the result was the suspicion from medical personnel that the promises that are given will not materialised by the next managers. This fact discourages the doctors to deal with the administrative role because this role is considered to be not attractive and with risk.

An additional reason for the bad professional relations is manager’s depreciation from the doctors. Doctors say that the managers do not have the mental faculty to see the difference between hospitals and supermarket or doctors and funds. [10]

Researches: the opinion of health’s professionals about the changes – reforms

In a research that was carried out in 3065 doctors, nurses, heads nurses, medical directors and manager, in England, Wales, Australia and in the New Zealand were made questions with regard to the labour environment in the hospital, the existence of reciprocal confidence - common work and the autonomy of clinical professions. The results elect the dimension of opinions between medical, nursing and administrative personnel. The heads nurses and followingly the managers are more receptive in the various changes and reforms. On the other hand, doctors insist to work individually contrary to their manager that is advocates of team work. [11]

In corresponding research that concerned the modernisation of NHS in England with the completion of questionnaire from 1092 clinical directors and managers, the managers were again proved more optimistic as long as it concerns their relations with doctors [12]

Repercussions of intersectorial conflicts between medical and administrative personnel in the hospital

It has been realised that the poor professional relations between medical and administrative personnel are connected with problems in the organisation and in the operation of the hospital. The good labour relations between doctors and manager are related with the high satisfaction of personnel. At the same time is created a environment where are facilitated the recording and the report of errors. On the other hand the bad labour environment that is inspired from stress, fear, frequent alternations and voices have unfavourable consequences for the benefit of health’s services of the patients. Also, it harms the health of the patients and the personnel’s with likely extensions in the wider system of health. [13,14]

Ways of approach and improvement of labour environment between medical and administrative personnel

The high quality of health’s services is supported in the productive communication (partnership) between doctors and managers and also in the preparation of doctors to undertake leading roles. Each profession must recognize the possibilities of the other profession and not to face this situation competitively. The improvement of clinical leadership presupposes better practice for the doctors in the methodology of management and activation in order the clinical leadership to become more attractive. [15,16] As an example the imperial college of University of London in collaboration with the medical faculty of the same university where the graduates of medicine can study management (bachelor) for one year. It is a very popular department which was established in 1999, where the graduates of medicine extend their horizons. Moreover, in Israel, the health management is granted as speciality and diploma to the doctors by the equivalent Health Ministry. Between 17.000 doctors, 25 candidates each year participate in a program that is provided by various academic centres in Israel. Corresponding programs exist also for the nurses. [17] It is impossible all the doctors to become manager but the follow-up of seminars in the hospital, in academic institutions, or distance learning would be very beneficial for them. [18] At the same time the managers should learn more about the medicine. The managers need to be leaders, contacts, mediators and more generally they have to know how to manage the crises. [19]

The improvement of labour environment can be achieved via the creation of communication’s network between doctors and manager, with discussions, common spirit, evasion of personal attacks and observation of engagements. [20] The experience shows that the managers and the doctors need to be capable to develop a vision and objectives - aims via the suitable strategy in order to achieve their mission. This is possible with the common approaches as long as it concerns the autonomy of each profession and the regularisation of work (measurement and evaluation of clinical activity).

In the United Kingdom exists the paradoxical that the profession of doctor while theoretically is one of the most powerful, into practice doctors feel feeble because of the bureaucracy and the pressure that they have to face. In a case study that was given in a hospital of Norway, professionals of health were asked how they manage the conflicts in their working place. They answered that they use the following approaches, evasion or concealment of conflict, persuasion and negotiation. [21] Reciprocal estimate and approach would lead to a harmony situation that would be good for the two teams but much more the patients. [22]

Labour relations between medical and nursing personnel

Retrospection in the relations between medical and nursing personnel

The labour relations between medical and nursing personnel in the hospital need attention because they are the most complicated and influence immediately the patient. In the past was considered datum that exists an absolute agreement between the branches, in a hierarchical and introvert relation impregnated in preventions, where the doctors were superior and the nurses subjugated. An article of a psychiatric newspaper in 1967, the relation was presented as a game, fight of force, where the doctors “handled” the nurses as “their pieces” [23] Nowadays, the relations between doctors and nurse are continuously developed because of recent changes including the fact that the nurses are not only female and also because many of them are graduates of academic faculties. At the same time the commercialisation of medical care shook the world.

Researches: relations between medical and nursing personnel

In a research that was carried out in 2002 and concerned nurses, doctors and administrative employees in a big network of hospitals, the majority reported that exists disjunctive behavior of doctors in their working areas, that influences negatively the nurses and the rest of the personnel even on issues of health preventing them from common work and influencing the course of patients. This is supported by additional studies that the communication and collaboration between nurses and doctors have important effect in the environment of work and in the clinical course of patients. [24]

In a questionnaire of 69 questions that examined the effect of medical sovereignty in the hospital and was supplemented by 133 nurses in Australia and 108 nurses in the Britain resulted that the majority of nurses declare disappointment with their job, feel unbearable pressure from the doctors and face intense psychological problems. [25]

Reasons of conflicts between medical and nursing personnel

The non favourable conditions in which the most nurses work, low economic rewards, limited professional autonomy and limited attendance in the decision-making have unfavourable consequences in the relation between doctors and nurses. If the relations are positive, the nurses it is more likely to feel satisfied with their environment of work. The labour satisfaction maintains the internal balance of nurses, prevents the labour overstrain (job burnout) and helps in the high productivity.

Other obstacles in the collaboration between doctors and nurses are the lack of communication and reciprocal respect. The studies that have been carried out show that the members of the particular branch see their selves “mainly as representatives of their science” and not as members of a total in which they do not exist limits between the various sciences. Nowadays, nurses want to be more independent and also want to have professional competences and responsibilities for the care of patient. They dedicate more time in the patients than the doctors and often have essential proposals in order to change the therapeutic metres. Sometimes, the doctors ignore the proposals of the nurses, this fact shows that they do not want the feedback with result the nurses to feel bad. It is a fact that the most nurses are completely worked out, but they feel that the doctors do not appreciate their knowledge and their qualifications.

Moreover, important role plays the differences in the income and the professional burn out, the lack of self-confidence that characterizes a lot of professionals of health and the problems that are not common with the working place, as the marital problems, the narcotics, the alcoholism, the stress, the economic problems and finally the mentality of nurses to accuse the other for problems that exist in nursing [26]

The results of collaboration between doctors and nurses

The environment of collaboration in the relation between doctors and nurses has positive effect in theirselves and in the patients. As long as it concerns the patients, the collaboration contributes in the satisfaction of doctors and nurses, in the positive development of patient’s health and in the reduction of medical errors.

As long as it concerns the nurses, the collaboration contributes in their satisfaction, in the reduction of labour stresses, in the alleviation of nurses’ alternation, in the communication between the functionals of health, in the comprehension of nurse’s role and in the improvement of their output and all this helps the autonomy, the control of theirselves and the enlargement of work (job enrichment and job enlargement).

As long as it concerns the doctors, the collaboration contributes in their satisfaction, in the reduction of labour stress and general in the estimate of nurse’s role from them.

In the operation of an organism, the collaboration between doctors and nurses decreases the costs and contributes in the increase of output and the effectiveness of workers. [27]

Conclusions

The good labour environment should constitute the first priority in the units where their main product is based on the factor of production. Consequently the units of health’s services as are the hospitals owe to interest mainly for the labour environment, the labour relations and the professional satisfaction of their workers.

References

1. Louise B. Work relationships. Managing the Emergency Department: A Team Approach. Dallas, Tex: American College of Emergency Physician,1992.
2. Terzidis k, Tzortzakakis, K. Administration of human resources Administration of Personal. Athens, Publications Rosili Michaeli, D. 2004.
3. Third Inquiry seminar focused on .culture. Culture and its impact on the quality of.care. Culture - professional and managerial cultures and their impact on the quality of service The Bristol Royal Infirmary Inquiry, 2002; Phase Two - .Seminar Three.
4. Edwards N. Doctors and managers: poor relationships may be damaging patients-what can be done? Qual. Saf. Health Care, 2003; 12 (Suppl_1), i21-i24.
5. Zupko K. Why physicians are often disappointed with their practice administrators and managers. BMJ, 1995; 311 (7005): 586.
6. Davies H.T.O, Hodges, C.l, Rundall, T.G. Views of doctors and managers on the doctor and manager relationship in the NHS. BMJ.2003 326 (7390): 626-628.
7. Atun R.A. Doctors and managers need to speak a common language. BMJ,2003; 326 (7390): 655.
8. Edwards N. Doctors and managers: building a new relationship. Clin. Med.,2005; 5(6):577-579.
9. Davies H.T.O, Harrison S. Trends in doctor-manager relationships. BMJ, 2003; 326: 646-649.
10. Edwards N, Marshall, M. Doctors and managers: a constructive dialogue has to replace mutual suspicion. BMJ, 2003; 326 (7390):116-117.
11. Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management and modernisation: a “danse macabre”. BMJ. 2003; 326: 649-652.
12. Davies H.T.O, Harrison S. Trends in doctor-manager relationships. BMJ, 2003; 326: 646-649.
13. Edwards N, Marshall M. Doctors and managers: a constructive dialogue has to replace mutual suspicion. BMJ, 2003; 326 (7390):116-117.
14. Philipp R, Dodwell P. Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload. Occup. Med. (Lond), 2005;55(1): 40-7.
15. Edwards N. Doctors and managers: building a new relationship. Clin. Med., 2005; 5(6): 577-579.
16. Atun R.A. Doctors and managers need to speak a common language. BMJ, 2003; 326 (7390): 655.
17. Weinstein S. M, Antonova S, Goryunova M. Enhancing nurse-physician collaboration: a staffing innovation. J. Nurs. Adm. 2003; 33(4):193-195.
18. Crosson F.J. Kaiser Permanente: a propensity for partnership. BMJ,2003;326: 654.
19. Atun R.A. Doctors and managers need to speak a common language. BMJ, 2003; 326 (7390):655.
20. Thomas H. Clinical networks for doctors and managers. BMJ, 2003;326 (7390): 655.
21. Skjorshammer M. Co-operation and conflict in a hospital:interprofessional differences in perception and management of conflicts. J.Interprof. Care, 2001;15(1):7-18.
22. Nash D. Doctors and managers: mind the gap. BMJ, 2003; (7390): 652-653.
23. Stein L.I. The doctor-nurse game. Archives of General Psychiatry,1967; 16(6):699-703.
24. Rosenstein A.H. Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 2002;102(6): 26-34.
25. Adamson B.J., Kenny D.T., Wilson-Barnett J. The impact of perceived medical dominance on the workplace satisfaction of Australian and British nurses. J. Adv. Nurs., 1995 ; 21(1):172-83.
26. Rosenstein A.H. Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 2002;102(6): 26-34.
27. O’Brien-Pallas L., Doran D.I., Murray M., Cockerill R., Sidani S., Laurie-Shaw B., Lochhass-Gerlach J. Evaluation of a client care delivery model, part 1: Variability in nursing utilization in community home nursing. Nursing Economics, 2001;19(6): 267-276.