**3. Psychosocial and organisational work environment**

Job satisfaction and dissatisfaction are concepts frequently discussed to describe how satisfied healthcare workers are with their work environment and working conditions. The endpoint of these discussions is voluntary or non-voluntary turnover, or adequate staffing within the organisation. Organisations such as operating departments, which are complex adaptive systems, should always be prepared, making the workplace as attractive as possible, as turnover and training of new staff are costly and require thoughtful planning and resources from the organisation. Turnover within the organisation is common, for example, when employees change

#### *What Makes It Tip Over and How Can It Be Prevented?: Challenges in Psychosocial and… DOI: http://dx.doi.org/10.5772/intechopen.109244*

their residence (voluntary turnover), choose to study further (voluntary turnover) or retirements (could be voluntary or non-voluntary turnover). However, voluntary turnover, when nurses with good skills, competencies, experiences and of working age leave their workplace due to job dissatisfaction, is serious and needs to be addressed.

Psychosocial and organisational factors in the healthcare environment interact, and they may contribute to nurses' and other professionals' decisions to stay or leave. On a psychosocial level, personal health [30] and possibilities to develop one's skills and knowledge at one's workplace, feeling that one's work has a meaning and relationships [31] with colleagues and managers are some factors, which affect job satisfaction. Lee and MacPhee [32] explained that nurse-physician relationship in perioperative settings was related to nurses' job satisfaction, and emotional exhaustion was the key predictor for nurses' job satisfaction and intention to leave. Furthermore, perioperative nurseto-nurse violence [33] and physician-to-nurse mistreatment [34] have been shown to cause high-stress levels [34] and depressive symptoms [33] in perioperative settings. Incivility or bullying leads to stress at work, impacting patient safety [35]. In contrast, perioperative nurses report that resolving issues leads to better patient outcomes, greater satisfaction in the workplace and heightens organisational commitment [36]. Villafranca and Hiebert [37] stated that the young clinicians who were inexperienced, female, non-heterosexual, worked as a nurse and worked in private care were groups that were more likely to be exposed to disruptive behaviour in their workplace.

On a personal level, Clausen and Burr [38] pointed out that not finding any meaning in one's work and not having any organisational commitment were associated with long-term sickness. Moreover, demanding work schedules, working night shifts and unsocial hours have been shown to have a negative impact on sleep [39]. According to Zhao and Bogossian [40], shift worker nurses are 1.15 times more likely to develop low back pain. In a more organisational level, factors such as re-organisation, meaning (ever-) changing structure in the organisation versus stability in the organisation, working schedule or hours [41] and recovery [42, 43], salary [30], number of people working at one's workplace [44] and leadership have further impact on whether one feels satisfied with his or her work. In summary, operating rooms are complex systems. Preventing perioperative nurses, nurse assistants or anaesthesiologists from leaving their workplace prematurely often requires several parallel measures.

#### **3.1 Nurse managers' role in staff 's well-being**

As studies by Logde, Rudolfsson [4] and Arakelian, Rudolfsson [45] pointed out, the first-line manager can be someone who, by his or her actions or lack thereof, is experienced as a facilitator and someone who contributes to staff's well-being or someone who is the reason for perioperative nurses leaving their workplace. This is valuable knowledge for leaders and managers in healthcare in perioperative departments, namely knowing that their role is crucial and that they can prevent loss of personnel. Leaving one's workplace was described as a process, where perioperative nurses had considered talking to their closest managers about it for a while. Nonchalance on the part of the managers and feeling that they were not needed in the organisation made the nurses take the step to quit their jobs. However, the nurses argued that when the decision was made to leave one's workplace, nothing, not even the best salary in the world, could change their mind. That is why nurse managers should be present and in close contact with their staff, being aware of their staff's needs on a personal level.

Nurse managers are important for both quality of patient care [46] and the staff's well-being [45, 47]; they desire to become nurse managers to do their best for the patients and their fellow employees, finding strength in their employees [47]. Nurse managers have described challenges they encounter, which are unique to perioperative settings [48]. Some challenges mentioned were that the nurse manager felt burdened by tasks that could be performed by other professions, for example, planning staff work schedules and lunch breaks, working as clinical nurses, being in the middle of the staff's personal needs and the organisational needs, challenges described with the ever-changing organisation and need to find tasks suitable for staff who physically were not able to work with the physical demands of static work of, for example, operating room nurses (this is the case of nurses who are getting closer to retirement).

Unfortunately, not all nurse managers have the proper university education in management. This is a serious issue that should be addressed in health care, namely, to educate and require that they have proper education and training in future. From a caring science perspective, Bondas [49] discussed the concept of "caritative leadership", which is derived from Eriksson's theory of "caritative caring" [50]. The core of caritative leadership is the Caritas concept of human love and mercy, which in caritative leadership is directed towards both patients and employees. In other words, it means seeing the uniqueness of the employees and their abilities to "minister to" or help the patients. Fredriksson and Eriksson [51] pointed out the importance of a caritative conversation between the nurse managers and their employees, by creating a room or space between them. Such a conversation metaphorically serves as "compassionate love" in professional commitment and organisational tasks [49]. Solbakken and Bergdahl [52] emphasised the importance of reflection, time and space and a balance between these for nurse managers, which metaphorically was discussed as rooms in the "house of leadership". The rooms were the patients' room, the staff room, the organisational room, the superior's room and the secret room. Caring in caritative leadership, according to Solbakken and Bergdahl [52], is a conscious movement or a metaphoric walk between the different rooms, as described above, to create a caring atmosphere. The secret room is a place where the managers have the opportunity to be alone with their own reflections and think things over.

#### **3.2 Job demand-control-support and organisational and relational justice**

Karasek [53] introduced the demand-control-support model, explaining that employees that receive support (both managerial and collegial) and feel high control and have low demands in their work are more likely to be healthy, or are in a healthy workplace. In contrast, those who do not receive support and feel high demands with no control, are in the high strain and more likely to become sick (burnout and other physical diseases). The latter presents risks for unhealthy or dangerous work. Those individuals who reported low well-being, low zest for work (meaning emotions about one's work, low means feeling discomfort or aversion towards work) and high intention to leave are the ones in the high strain field, experiencing high demands and low control. These individuals are, in other words, in unhealthy environments. Moreover, Karasek and Theorell [54] pointed out that employee health is positively related to feelings of high job control and to receiving social support in the workplace and is negatively influenced by high work demands [53]. Job demand, job control and perceived fairness in the organisation (in organisational and social work environment) are important in the work environment [55, 56]. These factors affect sleep quality and short-term recovery. Furthermore, high work demands and low sense of

#### *What Makes It Tip Over and How Can It Be Prevented?: Challenges in Psychosocial and… DOI: http://dx.doi.org/10.5772/intechopen.109244*

control affect the blood pressure negatively [57, 58]. Moreover, effort-reward imbalance may lead the nurses to quit their jobs [59]. Perioperative nurses, nurse assistants and anaesthesiologists have an imbalance in their job demand and job control, as they do not have control over the physical work environment or working conditions (for example, lunch breaks, which patients they care for, order of patients and anaesthesia methods changing with short notice); perioperative nurses and nurse assistants must adapt to changes in anaesthesiologists and the surgeons' decisions in patient care, and the changes occurring in the organisation. The workload is often high due to the growing number of surgeries, long work hours and personnel loss [4, 60], now more than ever, after COVID-19.

A study using Karasek's demand-control-support model [61], performed in perioperative settings, emphasised that 30% of the approximately 955 respondents (perioperative nurses, nurse assistants and anaesthesiologists) sometimes had thoughts of leaving their workplace during at least one month in the last year. Lower social support, lower zest for work or feelings about one's work, and thoughts about leaving one's workplace were interconnected. None of the perioperative nurses, nurse assistants, nor anaesthesiologists was in the high strain (low support, high demands and low control). Operating room nurses were in the "active field", according to the model, which means they felt they were in high control, despite feeling high demands. Nurse anaesthetists and nurse assistansts nurses were in a passive field with low demands and low control, and the anaesthesiologists, younger employees, and those with good well-being and high zest for work reported feeling low demands and high control (thus, being in the low-strain field).

Relation with one's superior manager is one of several factors in the work environment affecting employee health, and organisational justice and relational justice describe two of them [62]. There are four dimensions in organisational justice (or fairness in the organisation or being treated fairly), and interpersonal justice or relational justice (also referred to as interactional justice) is one of them. It highlights the superior's relationship with his or her employees, or how superior managers treat their employees. In other words, it means how employees' personal views and rights are treated by superior managers, or whether the employees are treated impartially, truthfully and with kindness. Relational justice or being treated fairly at the workplace is also linked to employee health in the workplace [63–67].

First-line managers, who offer support to their nurse employees, play an important role in their well-being [68] and job satisfaction [45], and employees who are content with their work are more engaged in their workplace [54, 69]. Employees with higher organisational justice also have higher well-being [64, 65]. On the other hand, low organisational justice affects quality of sleep negatively [55], causing stress and employee's possibility for recovery [70]. Working with work environment management systematically, a cohort of 500 employees in perioperative settings indicated higher scores of organisational justice, which means positive or good organisational justice (a higher number of total scores between 6 and 30 indicates good organisational justice, and the group had 25 and 26 at measurement in two-time points). A closer look at relational justice in the same cohort showed that timely feedback about decisions and being treated kindly by one's supervisors who showed consideration had the most impact on employees' well-being [71]. It is essential that supervisors treat their employees with fairness and create a friendly, welcoming workplace, where employees feel a balance in work demands and control of their work tasks, receive support from supervisors and colleagues and want to remain, and newcomers want to come and stay. Supervisors have the power to affect their employees' health and well-being.
