key: cord-0813678-3v9ougm6
authors: Fereidouni, Armin; Teymoori, Esmaeil; Maleki, Zahra; Ghanavati, Maryam; Vizeshfar, Fatemeh
title: Relationships between Job Satisfaction of Operating Room Nurses and hospital's Compliance with Protective Guidelines (Guidance) during Covid-19 Pandemic from the perspective of operating room nurses; A Cross-Sectional Study, Iran
date: 2022-05-02
journal: J Perianesth Nurs
DOI: 10.1016/j.jopan.2022.03.007
sha: e590c36c82be534d954217aa5cba72b1fb4fa853
doc_id: 813678
cord_uid: 3v9ougm6

PURPOSE: : Covid-19 pandemic is considered the biggest threat to the human health in the recent century. During emergency surgeries, the possibility of infection of members of the surgical team with Covid-19 increases due to the direct contact with patients. The present study has been conducted aimed to investigate the Relationships between Job Satisfaction of Operating Room Nurses and hospital's Compliance with Protective Guidelines (Guidance) during Covid-19 Pandemic from the perspective of operating room nurses. DESIGN: : This was a descriptive and cross-sectional study conducted from September 22, 2020 to April 21, 2021. METHODS: : This study was conducted on 926 nurses working in operating rooms in 15 Metropolises of Iran. The sampling method in this study was multistage clustering. The questionnaire was sent to the target group through social apps (WhatsApp and Telegram). The collected data were analyzed by SPSS software version 26 using descriptive and analytical statistics. FINDINGS: : The mean age and job satisfaction of the participants were 28.81 ± 5.64 years and 51.15 ± 11.45, respectively. 259 participants (27.97%) reported very good job satisfaction. Also, the mean hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses was 42.29 ± 7.11. The results of the present study showed a significant relationship between job satisfaction and hospital's compliance with protective guidelines during Covid-19 pandemic (P-value ≤ 0.001). CONCLUSION: : Optimization of infrastructure, improvement of management decisions and increasing human resources in a crisis can affect the quality of performance and job satisfaction of operating room nurses. The researchers suggest that health system managers can contribute to the safety and efficiency of the existing human resources by taking measures to increase job satisfaction.

Covid-19 pandemic is the biggest threat to the human health in the recent century (1) . At the frontline of this global crisis, health care professionals (HCPs) are responsible for diagnosing, treating, and implementing patient care decisions (2) . The possibility of infection of health care professionals with Covid-19 due to direct contact with patients is higher than others (3) .

According to the Secretary-General of the World Health Organization, 10% of patients with Covid-19 around the world are health care professionals (4) .

Given that surgical care is a key component of any health system (5) , the task of operating room nurses as a member of the surgical team is to provide timely and quality care to patients (6) . Nurses are an important part of human resources in the health system and job satisfaction of nurses during recent pandemic has been much considered (7) . This job satisfaction is affected by factors such as physical and mental stress, well-being, workplace conditions and workload. Studies have shown that job satisfaction is very important among health staff (8, 9) .

Increasing job satisfaction leads to reducing complaints by staff, reducing absenteeism, increasing morale of staff, and improving the quality of patient care and as a result, patients' satisfaction with the services delivered (8, 9) . In this regard, the job satisfaction of frontline medical staff is directly associated with the implementation and effectiveness of strategies for the prevention and control of major crises (10) .

About 234 million surgeries are performed annually in the world. Therefore, 1 out of every 25 people undergoes surgery (11) and annually, 791,000 patients in the United States need emergency surgery (12, 13) . During surgery and anesthesia stages, the production of aerosols and surgical smoke increases the possibility of infection of members of the surgical team with Covid-19 (14) . Studies have reported more than 80 types of toxins in surgical smoke (15) (16) (17) (18) .

In addition, a direct relationship is found between the complications of this smoke and the transmission of bacterial and viral infections and possibly the transmission of Covid-19 (19) (20) (21) . Therefore, it is essential for surgical team members and medical centers to comply with protective guidelines to prevent Covid-19 infection in the operating room (22, 23) . In summary, these guidelines include restricting surgery to emergency and necessary surgeries, using personal protection equipment for the surgical team, observing safety standards, and operating room equipment such as operating room ventilation, filtration, and separation for definitive patients with Covid-19 (13, (24) (25) (26) (27) (28) .

Although vaccine production today has reduced mortality and morbidity due to Covid-19, the development of new variants of SARS-Cov-2019 virus due to successive mutations has jeopardized the efficacy of vaccination in the future (29) . A study by Ikegame shows that Sputnik v vaccine is not sufficiently effective against the African mutation B1.351 (30) . A review of a prospective model also shows that many scientists expect the virus that causes Covid-19 to become endemic and persistent, which increases the importance of compliance with protective guidelines (31) . In addition, the American College of Surgeons considers that the most effective way to prevent the transmission of the disease is to reduce the time spent in contact with the carriers and to comply with protective guidelines (32) .

Increasing job satisfaction improves the quality of patients' medical care (33) . As a result, in addition to maintaining an adequate human resource against Covid-19, maintaining the health and well-being of health care professionals (HCPs) is essential for planning against the underlying pandemics ahead (34) . Therefore, the present study was conducted for the first time in Iran aimed to investigate the Relationships between Job Satisfaction of Operating Room Nurses and hospital's Compliance with Protective Guidelines (Guidance) during Covid-19 Pandemic from the perspective of operating room nurses.

This cross-sectional study was conducted on 926 operating room nurses from September 22, 2020 to June 5, 2021 in 15 metropolises in Iran. The sample size based on the study results of Timothy et al. (30) (p = 0.48) was obtained n = 369 using the following formula n = Z 2 P (1-P)/d 2 with confidence level = 95% and d (margin of error) = 0.05 and considering the design effect = 2.5 the sample size was calculated n = 922.

The sampling method in this study was multistage clustering. At the first stage, 15 metropolises (clusters) were selected by simple random sampling in Iran. At the second stage, the 3 main hospitals admitting patients with Covid-19 in each metropolis were selected by simple random sampling (using a lottery). At the next stage, with the permission of the Research Department of the University of Medical Sciences of each city, a list of operating room nurses from hospital centers was prepared. Finally, according to the list, they were randomly selected (random number table), and then the link to the online questionnaire was sent to the target group via social apps (WhatsApp, Telegram) using the university's virtual messaging system. If they did not want to cooperate, they were tracked up to 3 times; otherwise, the next random number was selected.

The study inclusion criteria included at least an operating room associate's degree and more than 3 months of work experience as a scrub or circular nurse in the operating room. The study exclusion criteria were incomplete questionnaires and moving to other wards or hospitals. IP filtering was used for the design of the online questionnaire to prevent repeated responses, and participants could refuse to complete the questionnaire at any time. Before completing the questionnaire, the participants were informed of the objectives of the study by sending an SMS and informed written consent was obtained from each participant electronically before Logging into the link of the questionnaire.

In the present study, 3 questionnaires including demographic information questionnaire (age, gender, marital status, education level, employment status, type of hospital, and work experience), Minnesota Job Satisfaction Questionnaire (MSQ) (35) and the researcher-made questionnaire of protective guidelines during Covid-19 pandemic in the operating room were used. All 3 questionnaires were designed as a comprehensive questionnaire in a link. In order to better understand the questions and identify possible problems of conducting the study, a pilot study was conducted on 150 operating room nurses. In the present study, the researcher-made questionnaire was used to measure hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses. In order to design the questionnaire questions, literature review (13, 26, 27) and guidelines of the World Health Organization in relation to protective guidelines for health care professionals (23) of Center for Disease Control and Prevention (CDC) and the American College of Surgeons were used (36) . In order to confirm the validity of the questionnaire, 3 methods of face validity, content validity and construct validity were used. In order to confirm the face validity qualitatively, 8 operating room nurses and 2 nursing faculty members were interviewed face to face and the appropriateness of the items with the subject and ambiguity in the meaning of the words or phrases of the items were investigated. In order to confirm the face validity quantitatively, the item impact quantitative method was used with the help of 10 tool specialists and nursing professors. Impact score for all items was more than 1.5. In order to confirm the content validity qualitatively, after interviewing 10 experts (medicine, nursing, epidemiology), they were asked to review the questionnaire in terms of the correct writing method and the importance of each item. In order to confirm the content validity quantitatively, content validity ratio (CVR) and content validity index (CVI) were used. In order to confirm CVI, four criteria of simplicity, clarity, specificity and relevance were considered based on 4-option Likert scale based on content validity index of Waltz and Bausell (37) . According to the results obtained from the quantitative content validity, CVR was reported to be higher than 0.62 for every 20 items. According to Lawshe Table and the evaluation of 10 experts, items with a score of 0.62 and above were retained (38) . CVI of the questionnaire was 0.94 and at an appropriate level. The construct validity of the questionnaire was confirmed by experts as well as exploratory factor analysis using the principal In present study, only factor loads greater than 0.3 were considered as significant factor loads. In this analysis, based on the eigenvalue greater than 1, 5 factors were extracted, which explained 51.17% of the total variance of the model. These 5 factors were identified as the strongest factor loads for each factor. Accordingly, the first factor is "protective guidelines before surgery", the second factor is "surgical type guidelines", the third factor is "personal protection equipment guidelines", the fourth factor is "environmental ventilation and air filtration guidelines" and the fifth factor is "temperature and humidity environmental guidelines".

The reliability of the questionnaire was determined 0.84 by Cronbach's alpha coefficient and in a pilot study with a sample size of n= 150. Therefore, this questionnaire can be used as a 

For data analysis, we used descriptive analysis including frequency, percentage, mean, and standard deviation, and analytical statistics for qualitative and quantitative data with normal distribution. The differences between subgroups were compared using Chi-square test. The normality of all quantitative variables was investigated using Kolmogorov-Smirnov test and statistical graphs (histogram and box-plot). The collected data were analyzed by SPSS software version 26. P-value less than 0.05 was considered statistically significant.

This study has been approved by the Ethics Committee of Shiraz University of Medical Sciences with the code of ethics IR.SUMS.REC.1399.856. All information obtained from the participants in the study was kept confidential and the names of the participants were replaced with codes.

The mean age of 926 nurses participating in the study was 28.81 ± 5.64 years. The majority of samples were female (n = 790) (82.1%) and single (n = 495) (51.5%). A statistically significant relationship was found between age (P-value ≤ 0.001), marital status (P-value = 0.010), work experience (P-value ≤ 0.001), employment status (P-value ≤ 0.001), Covid-19 infection (P-value ≤ 0.001) and job satisfaction. The highest job satisfaction was related to young people, single in the age group of 20-30 years, with 1-5 years of work experience and contractual employment status. Chi-square test showed that people with higher job satisfaction were less likely to develop Covid-19 (P-value ≤0.001). In this study, no significant relationship was found between gender, education, type of hospital and job satisfaction. Table 1 shows the distribution of demographic information and its relationship with operating room nurses' job satisfaction.

The mean job satisfaction of nurses was 51.15 ± 11.45. 533 participants (57.65%) showed moderate job satisfaction, 134 participants (14.38%) showed poor job satisfaction and 259 participants (27.97%) showed very good job satisfaction. Figure 1 shows job satisfaction of operating room nurses separately.

The mean hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses was 42.29 ± 7.11. In the present study, 60 participants (6.5%) reported a low level of hospital's compliance, 550 participants (59.4%) reported a moderate level of hospital's compliance and 316 participants (34.1%) reported a high level of hospital's compliance with the guidelines. Table 2 shows the percentage and frequency of hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses Chi-square test showed a significant relationship between job satisfaction and hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses (P-value ≤ 0.001). Table 3 shows the relationship between job satisfaction and hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses

The most common reasons for non-compliance with some of protective guidelines during Covid-19 pandemic reported by operating room nurses included reduced access to personal protective equipment (44.49%), difficulty in complying with protocols in the operating room (32.23%) and mismanagement in the operating room (23.28%).

The odds of developing Covid-19 was 59% lower in those with moderate job satisfaction than in those with poor job satisfaction (p-value>0.001, OR=0.41, 95%Confidence Interval=0.25-0.66). Also, those who had very good job satisfaction were 38% less odds to develop Covid-19 than those with poor job satisfaction (p-value=0.014, OR=0.62, 95%Confidence

Interval=0.43-0.91).

This study has been conducted to investigate the Relationships between Job Satisfaction of Operating Room Nurses and hospital's Compliance with Protective Guidelines (Guidance) during Covid-19 Pandemic from the perspective of operating room nurses. The results show a significant relationship between job satisfaction and hospital's Compliance with protective guidelines and increased hospital's Compliance with protective guidelines during Covid-19 pandemic led to increased job satisfaction of operating room nurses. Consistent with the study results, Yu et al. believed that the job satisfaction of medical staff is directly associated with the implementation and effectiveness of strategies for the prevention and control of major crises (10) . Improving the health of operating room nurses and patients, which is affected by hospital's compliance with protective guidelines, can be achieved by increasing the job satisfaction of nurses, especially in the current situation that Covid-19 pandemic has added to the importance of compliance with protective guidelines.

In this study, job satisfaction was investigated as an independent variable. The results of the present study showed that more than half of the participants in the study had moderate job satisfaction. In a study, Gimenez-Espert et al. reported high job satisfaction of nurses during Covid-19 pandemic. In this study, consistent with the present study, job satisfaction was significantly related to measures, information and resources of Covid-19 prevention, and it is interesting that according to this study, the more resources available to meet job challenges, the higher job satisfaction (39) . In a study that investigated satisfaction of nurses working in public hospitals, nursing unit managers reported that lack of support nurses and staff leads to a reduction in nurses' job satisfaction. Lack of staff caused nurses to take on many responsibilities and therefore naturally leading to physical and mental fatigue and burnout of nurses. In addition, according to reports of nursing managers, the lack of resources and poor infrastructure of hospitals had a negative impact on workload and caused more time constraints for nurses (40) . In addition, in a study in South Africa, nurses were significantly dissatisfied with the resources available to provide nursing care (41) .

The results of the present study show that from the perspective more than half of the participants reported a low level of hospital's compliance with protective guidelines during Covid-19 pandemic. Timothy et al. in their study aimed to evaluate compliance of health care providers with protective guidelines during Covid-19 pandemic showed similar results. Of course, the difference between a study by Timothy and the present study is the site of the study, which in the present study is the operating room and in a study by Timothy is the outpatient ward of the hospital. Since in the present study, reduced access to personal protective equipment (PPE), difficulty in complying with protocols in the workplace and mismanagement in the operating room were among the most common reasons for hospital's non-compliance with protective guidelines during Covid-19 pandemic from the perspective operating room nurses, the researchers recommend that, given the current epidemic, it is essential to improve infrastructure and management decisions and increasing human resources in a crisis can affect the quality of performance and job satisfaction of operating room nurses. (42) .

In the present study, younger people had more job satisfaction. Asghari et al. in their study, which investigated the factors affecting nurses' job satisfaction, reported that job satisfaction increased with age (43) . Kuei-Yun Lu did not find this relationship significant in his study.

However, contrary to both studies, in our study, the relationship between job satisfaction and age was found to be inverse (44) . It can be explained that during Covid-19 pandemic, young people probably had more work potential, greater adaptability skills, less burnout and more youthful spirit than older people. On the one hand, to prove their abilities to their superiors and achieve a more secure job position, young people maybe have a greater desire to work.

The results showed a significant relationship between job satisfaction and employment status.

A study by Sadeghi Kortovigi, contrary to the results of our study, showed that employment status had no significant relationship with nurses' job satisfaction (45) . In addition, work experience, job category and education were among the items investigated in this study and their relationship with job satisfaction was not significant. In a study by Sadeghi Kortovigi, the cases were investigated in more details than in our study, and the factors were measured separately in relation to job satisfaction. Of course, one of the limitations of this study is that it is limited to two military hospitals, which cannot be generalized to other hospitals and the conditions of other nurses (45) .

A study by Kitajima et al. (2020) contrary to the present study showed that those with higher work experience had higher job satisfaction (46) . The reason for this difference can be explained by the fact that by increasing work experience, the probability of burnout is higher; as a result, job satisfaction is higher in those with less work experience.

In the present study, nurses working in the operating room without a history of Covid-19 infection had higher job satisfaction. The results of our study consistent with a study by Labrague et al. showed that fear of Covid-19 in nurses leads to reduced job satisfaction and increased financial burden of the organization. In addition, fear of Covid-19 can interfere with nurses' performance and, as a result, can reduce compliance with health protocols (47, 48) . The effect that Covid-19 has had on all global levels is very great (49) . This has caused individual and social challenges in terms of health, economics, politics and society (50) .

Because nurses are in close contact with a variety of illnesses and covid disease, their efforts over other occupations are significant (51) . Among them, the efforts of nurses are very important (52) . Therefore, any information that we can provide that would reduce their physical and mental burden would be an investable effort (53) .

This study had some limitations, including the fact that no similar study was found Job Satisfaction of Operating Room Nurses and hospital's Compliance with Protective Guidelines (Guidance) during Covid-19 Pandemic from the perspective of operating room nurses in Iran.

Therefore, we attempted to use the closest studies to the subject. In addition, for this study, we can get help from other medical centers that do not admit the patients with Covid-19, which was not possible in our study. Another limitation of the study is investigation of only 3 of the most common reasons for non-compliance, while non-compliance with health guidelines can be due to several factors that are not addressed in this study and it is suggested to do so in future studies in this regard. Another limitation of the study is the use of a selfreport questionnaire, especially for hospital's Compliance with protective guidelines during Covid-19 pandemic, which leads to the possibility of participants refusing to tell the truth.

This study emphasizes the importance of job satisfaction of operating room nurses, especially during Covid-19 pandemic, and shows that job satisfaction of operating room nurses is affected by the hospital's compliance with protective guidelines during Covid-19 pandemic.

In addition, optimization of infrastructure, improvement of management decisions and increasing human resources in a crisis can affect the quality of performance and job satisfaction of operating room nurses. The results of the present study can be considered for other pandemics that may occur in the future. 

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