INVESTIGATING JOB SATISFACTION AMONG EMERGENCY DEPARTMENT WORKERS IN A PRIVATE HOSPITAL DURING THE PANDEMIC

In Indonesia during the COVID-19 pandemic situation, there is a surge of health care demand that leads to exhaustion and resignation of health workers. The emergency department plays an important role in providing care in Surya hospital, but many factors due to the unpredictable nature of the emergency department influence health workers’ satisfaction. Managing job satisfaction is essential as it increases the commitment and human capital potential of an employee, which subsequently contributes to the quality of care provided to the patients. This research investigates job satisfaction among health workers in the emergency department of Surya Hospital. In-depth semi-structured interviews and direct observations were employed in the study. From this study synergized teamwork increases emergency workers’ job satisfaction. On the other hand, complex recruitment processes, lack of compensation and benefits policy, and ineffective communication flow decrease job satisfaction. This research could guide the mediation between health workers and hospital management in providing a better working environment in the emergency department.


Introduction
The emergency department (ED) portrays an important element of a health service in a hospital. It provides timely access to care from evaluation, stabilization, and treatment from mildly ill patients to seriously ill or injured patients ((ACEP), 2016). Type of patients arriving, the pace of the arrival or their acuity and severity level is unable to be predicted by the ED personnel, thus it may lead to long wait times, overworked staff, overcrowded departments, decreased of staff and patient satisfaction ((ACEP), 2016); (Nash, Zachariah, Nitschmann, & Psencik, 2007). Due to the ED's nature, the team often faces unpredictable challenges and crises daily, causing an increased level of stress on the staff than in other departments' (Yuwanich, Sandmark, & Akhavan, 2016).
Job satisfaction among health care professionals acquires significance to maximize human resource potential (Bhatnagar and Srivastava, 2012) and it is complex, multi-faceted, and non-linear. Job satisfaction of health workers have a positive effect on the quality of the care provided, as well on the patient safety issue (Staempfli & Lamarche, 2020), it is also related to other factors such as optimal work arrangements, participation in the decision-making process, effective communication, and able to express opinion freely (Bhatnagar and Srivastava, 2012). A report of an outstanding quality of care that was delivered by 81.3% of nurses that were satisfied with their job (Aron, 2015). Thus (Aiken et al., 2012) concluded that to improve patient safety and quality of hospital care cost-effectively is by targeting the hospital work environment, such as the worker's job satisfaction (Aiken et al., 2012).
The number of emergency department visits is increasing each year, there is an increase of 30% annually (Deviantony, Ahsan, & Setyoadi, 2017). Overcrowding in ED is caused by the imbalance of care demand to the available facility and staff of the ED, thus becoming an international problem as it can be seen in the USA, Europe, other Asian countries, Africa, and Australia (Kusumawardhani, Handiyani, & Nurdiana, 2021). An outbreak of Covid-19 was started in Wuhan China in December 2019, and the situation is rapidly evolving (Rasmussen & Jamieson, 2020). In March 2020 WHO declared Covid-19 as a pandemic and started to be found in Indonesia with increasing cases each day (Kementerian Kesehatan Indonesia (Kemenkes), 2021). By August 2021, there are more than 4 million people in Indonesia affected by Covid-19 and on average around 16 thousand people tested positive everyday (Kementerian Kesehatan Indonesia (Kemenkes), 2021). Hospitals and emergency rooms in many cities in Indonesia were overloads with Covid-19 patients, some of them have to temporarily close the emergency department due to full capacity ( CNN Indonesia, 2021). Many health workers in Indonesia prefer to quit their job in this era of the Covid-19 pandemic, due to high workload, high risk of infection, and unclear payment of incentives from the government as stated by doctor Eva Sri for Media Indonesia (Saragih, 2021).
There are some differences in the composition of a team working in ED for every hospital. In this private hospital in West Java, four main departments working together to provide care in the ED, such as nursing, administration, pharmacist, physician department. Surya Hospital is a developing hospital that has a capacity of 17 ED beds. The staff working in a shift consists of 3 nurses, 2 administrators, 1 pharmacist and 1 doctor. Before the pandemic, the number of patients visiting the ED still can be handled by the staff on duty. However, during the pandemic, there was a surge in the number of patients so that the staff on duty were overwhelmed and had difficulty handling them. There are several works of literature about job satisfaction limited to nurses in emergency departments but lacks data from other ED staff such as physicians, pharmacists, and administration officers especially in Indonesia. This research focuses on the following research question: 1) What are the factors influencing job satisfaction in the emergency department? 2) How can hospital management strategize to enhance job satisfaction?
With the above research questions, this research could guide the mediation between health workers and hospital management in providing a better working environment in the emergency department.

A. Job Satisfaction
Job satisfaction can be defined by affective orientations on the part of individuals towards roles which they are presently occupying (Vroom, 1964). It is how people feel about their job and its various aspects. (Rue & Byars, 2003) mentioned some factors that affect job satisfaction such as manager's concern for people, job design (scope, depth, interest, perceived value), compensation (external and internal consistency), working condition, social relationship, long-range opportunities, perceived opportunities elsewhere, and the levels of aspiration and need of achievement. All these factors can lead to job satisfaction or job dissatisfaction. When an employee is satisfied with his/her job, the level of commitment to organizations will be increased, on the other hand, when an employee feels dissatisfied with his/her job, it will lead to turnover, absenteeism, tardiness, accidents, strikes, grievances, sabotage and other forms (Rue & Byars, 2003). Job satisfaction is defined by (Hoppock, 1935) as any combination of physiological, psychological, and environmental circumstances that cause a person to feel satisfied with his/her job. (Vroom, 1964) stated that job satisfaction is a positive orientation of an individual towards all aspects of the work situation. (Locke, 1969) defines job satisfaction as a pleasurable or positive emotional state that results from the appraisal of one's or job experience. Overall job satisfaction is defined by a complex set of variables that are affected by the perception and expectation of the employee, a positive attitude towards a specific working experience (Thiagaraj & Thangaswamy, 2017).
Maslow proposed the hierarchical theory of five sequential order and progressive sets of needs. The order is physiological needs, safety, and security needs, love and belonging needs, status and prestige needs, actualization needs (Thiagaraj & Thangaswamy, 2017). It was thought that before being able to achieve the more complex needs (belonging and esteem), a person has to achieve the essential need before (physiological needs and safety) (Hassard, Teoh, & Cox, 2016).
Motivation-hygiene theory or duality theory was stated by Herzberg et al. (1959) where two main factors that affect job satisfaction: motivators and hygiene factors (Avoseh & Mejai, 2018). Motivators are from the internal states (work condition and feelings) of the personal mind that leads to job satisfaction. Including in the motivator factors are achievement, recognition, growth, and responsibility. On the other hand, hygiene factors refer to disruptions in the external work context and it contributes to job dissatisfaction. Hygiene factors including company and administrative policies, supervision, relationship with supervisors, work conditions, salary, relationship with peers, personal life, relationship with subordinates, status, and security (Smerek & Peterson, 2007).

B. Health Service
Health service is defined as an activity that is performed by an individual or organization service provider to an individual that comprises: (1) assess, maintain, or improve an individual's health; (2) diagnose an individual's illness, injury, or disability; (3) treat individual's illness, injury, disability or suspected illness, injury or disability; (4) disability service, palliative care service, or aged care service; (5) dispensing and prescribing drug or medicine (Australian Law Reform Commission, 2010). A good health service delivery is a substantial element for a health system to maintain population health status. Key characteristics of a good health service delivery including comprehensiveness (provide preventive, curative, palliative, rehabilitative, and health promotion services), accessibility, coverage, continuity, quality, person-centeredness, coordination, accountability, and efficiency (World Health Organization (WHO), 2010). The health system consists of all organizations, institutions, and resources that provide improvement of health (Organization, 2000).
Hospitals are playing an essential role in the health system by being instrumental in care coordination and integration of health care. It provides complementary and amplifies the effectiveness of the health system by providing continuously available services for acute and complex conditions (World Health Organization (WHO), 2020). The emergency department is part of the hospital service that provides a 24-hour service for emergency care, urgent care, primary care, and community health care services that are unavailable after hours. In general, three types of common care provided by emergency departments are emergency care, unscheduled urgent care, and safety net care (vulnerable populations that are unable to access care from other parts of the health care system) (Asplin et al., 2003). The emergency department also plays an important role as an entry point for hospital admission and is one of the key sources of hospital revenue (Heisler & Tyler, 2014).

Method
This study presented a single case study in Surya Hospital to induce the factors affecting job satisfaction among health workers in the ED. In-depth semi-structured interviews and direct observations are mostly used in the study. The purpose of qualitative research is to recognize a phenomenon in the natural context and to develop a theoretically driven mini theory or a conceptual model. The information was obtained from the interviews, direct observations, and recording of the interviews.
There are four main departments or categories of employees working together in the emergency room in the private hospital where this research took place. They are nurses, administrations, pharmacists, administrations and physicians/doctors. Referring to table 1, there are 15 respondents participating; from each department three to four employees were approached and interviewed. The interview was conducted outside working hours, to prevent distractions that may come from their duty and the right timing was important as the researcher and the informants wanted to prevent being rushed during the interview session. Each of the informants was given the same questions based on the research problems. Notes and voice recordings were taken during the interview process. In the beginning, the researcher has to gain trust from the informants because some questions are sensitive and some of them were afraid the data will be given to the superior management. A relaxed and casual interview was done to let the idea and thoughts flow through the interview questions. On-site observations and field notes were also taken to enhance the data collection. This interaction was done to see the congruence of the informants' behaviors in the working place and the answer given during the interview session.
To achieve credibility and internal validity, multiple types of data were gathered through multiple lenses with the practice of triangulation (Tracy, 2013). The searching process will be ended when the data reach saturation by means there are no more aspects to elucidate (Jonker & Pennink, 2010). Resonance can be achieved when the researcher can assist the readers to have a connection between a study's findings to their situation as stated by the concept of naturalistic generalization (Stake & Trumbull, 1982). This resonance determined the external validity or transferability of a study. The researchers also make sure to avoid subjective biases and individual points of view by using multiple people to code the data, having participants review the results, verify with more data sources, checking for alternative explanations, and review findings with peers.
A mini theory is defined as a theory that is only applicable for a certain situation (Jonker & Pennink, 2010). Thus by repeating the mini theory and applied it to different situations and times, then it can be constructed and validated to become a grand theory. The mini theory can also be tested using a quantitative method as a complementary (Strauss & Corbin, 1990). While the purpose of quantitative research is to use a former theory to frame and to understand the problem. Elaboration of the theory based on the findings, most often in the form of conceptual model and elaborations through hypotheses (Jonker & Pennink, 2010).

Result and Discussions
Teamwork is a collection of individuals with complementary skills who are committed to achieving a common team goal by being mutually accountable through sharing skills and knowledge in a supportive environment (Greenberg & Baron, 2003). Teamwork has become an important strategy to boost productivity and employees' flexibility. In the UK, 80.6% of organizations stated that they are already organized into work teams (Dhurup, Surujlal, & Kabongo, 2016). (Dhurup et al., 2016) stated that teamwork is one important aspect for long-term success for both employees and the organization. The synergized teamwork was described from the interview: "Most co-workers are within the same age, so we are more comfortable at work, they can understand our condition better and feel of kinship and friendship it's pretty good here."-Informant 3, Nurse "It's the co-worker first, if we have a good co-worker, we can work together as a team, so the work can be done completely." -Informant 5, Administration "Oh, it's so comfortable working here. I enjoyed it, first of all, it is because of the team. Starting from the superior, teammates, and the working environment is also good, making us comfortable." -Informant 6, Administration "The most important thing is co-workers because co-workers are also influential for comfort in a team" -Informant 7, Administration "The team supports each other to provide service so that it can run well, everyone willing to help each other, give each other input, and we have a good teamwork." -Informant 12, Pharmacy Most of the informants were giving good impressions towards the teamwork in their daily work, it was stated that having good teamwork is a major issue that brings comfort and excels working environment. Thus we conclude:

A. Proposition 1 (P1): Synergized teamwork (Variable 1 (V1)) positively influence job satisfaction (V5)
The recruitment process plays an important part of human resource activity for organizational success and requires good strategic planning (Taylor & Collins, 2000). Recruitment is a process of identifying job vacancies, analyze job requirements, and attracting potential candidates from within and outside of the organization to be evaluated and placed into an appropriate qualification of the job. Recruitment is not merely the number of humans, but a step further in developing and shaping the organization culture, looking at the attribute preference and about the current and future employees (Gopinath, 2021). The devotion of energies and focus to match the perfect candidates using a high-quality selection system sometimes brings challenges to the organization. The shortcoming in the recruitment process was described from the interview: "…with our lack of human resource, we automatically feel tired, exhausted, so the enthusiasm to work sometimes also decreases." -Informant 2, Nurse "First, please pay attention to the employees, our current number is very lacking, not only nurses, but doctors also need to be added." -Informant 4, Nurse "The workload is too much, in my opinion, the work is too much and the human resource is very limited in number, so if one is sick or on leave, we will lack power." -Informant 6, Administration "Due to limited personnel, it is difficult for us to triage patients, so that patients who should be prioritized cannot be prioritized and join the queue, no one has time to check." -Informant 14, Physician It was described that the informants experience a high workload, especially when the interview was taken place which is during the Covid-19 Pandemic. The high workload was due to inadequate human resources. It is a recruitment process and human resource planning has not succeeded to meet the desired needs. Thus we conclude:

B. Proposition 2 (P2): Recruitment process (V2) negatively influence job satisfaction (V5)
Compensation is a payment given by an employer to the employees as compensation or rewards (financial and non-financial) for the time, skills, effort made in fulfilling job requirements towards the organizational goals (Erasmus & Schenk, 2008). While benefits are packages to enhance the compensation received by the employees, it comprises of health, protection, savings, retirement program, health benefit for families, it may also comprise of organizational practices or policies that support the employees (Mabaso & Dlamini, 2017). The monetary reward has a powerful impact in determining job satisfaction. (Qasim & Syed, 2012) stated that emotional dissatisfaction may be developed when the employee is not well compensated. The emotional dissatisfaction will grow and accumulated causing unhappiness and un-satisfaction in working in the organization.
"In another hospital, even though he is tired of working, they get the benefits and extra incentives, we want to work according to what we get, we work to earn money as well as services to other."-Informant 3, Nurse "From my point of view, there are as if no rewards given to the employee, but only there are more tasks and responsibilities that are always assigned to us"-Informant 15, Physician "With a workload like this, incentives given should be more than this, because I compare it with my previous experience, with a workload like this, we should be able to get more. And every work we do should get a fee for service, whereas in this hospital the fee for service is not clear Physician It was stated that the informants were not satisfied with the compensation that was given by the hospital. Some of them were comparing with compensation and benefit received from other hospitals especially in the pandemic setting when the workload and the risk are increasing. Thus we conclude:

C. Proposition 3 (P3): Compensation and benefit policy (V3) negatively influence job satisfaction (V5)
An organization is seen as a communication system in which a larger system has supported by diffusion of information about the environmental factors and internal processes that are monitored by subsystems (Goldhaber et al., 1978). The information is important for coordinating the internal function of the organization and adapting to changes from the external environment (Thayer, 1968). Research regarding organizational communication has been conducted for decades, and it has been defined in several different ways (Graen, 1976). Two major perspectives are important for both the structural and dynamic properties of organizational communication: information flow (process perspective) and perception or attitudes (perception perspective) (Pincus, 1986). Down et al. (1973)  Employees' satisfaction with top management and the communication activities may influence job satisfaction (Ruch & Goodman, 1983). Creating a clear guideline of what information needs to be communicated to gain the trust and accuracy of the employee is also becoming a key (Syallow, 2019). The communication system was described from the interview: "The superiors often not looking what is the problem and look for the solution, but looking for who did the mistakes"-Informant 7, Administration "In my opinion, there is no place to give suggestions and inputs to the superior, there is no media"-Informant 1, Nurse "He must know and understand and be willing to listen to inputs and suggestions from subordinates, even though the inputs are not all carried out, it is better not to reject them straight away, he should sort out and accept all inputs."-Informant 6, Administration "If there are new regulations, they should be communicated to the implementing staff such as pharmacists and doctors, and for pharmacy supervisors, they should be more supportive of decisions made by employees, because we make decisions, not for ourselves, but also considering the benefits for patients and the hospital. We should be supported, asked why we made this decision, not that we are being blamed. Paying more attention to employees, they should be better equipped for decision making."-Informant 11, Pharmacy It was described that there is a lack of communication between the superior and the subordinates, some staff said that there are no media to give input and suggestions to the superior as if they are not heard and not being understood. Some staff also feel that they didn't get enough information about the new regulation. Thus we conclude: D. Proposition 4 (P4): Communication System (V4) negatively influences Job Satisfaction (V5)

Conclusion
As a service provider, Surya hospital should prioritize the service quality to the patient. The service provided might be affected by the job satisfaction of the employees, a satisfied employee is more motivated to work towards the organizational goals. Thus hospitals should give attention to the employees' job satisfaction to excel the hospital performance. The organization could improve on the latent variables from this study such as improving the recruitment process, compensation and benefits policy, and communication system in the organization.
The limitation of this study is that it only takes place in a single private hospital, and the interview was taken during the pandemic of COVID-19 which may give bias to the answer due to the overload of all healthcare services in Indonesia. Further studies in emergency department of other hospitals, such as government hospitals and teaching hospitals for comparative studies. Retrieved from https://www.alrc.gov.au/publication/for-your-informationaustralian-privacy-law-and-practice-alrc-report-108/62-the-privacy-act-and-healthinformation/definition-of-health-service/