Mental Health among hospital employees in a psychiatric facility

A qualitative study

Faculty of Health, Medicine and Life Sciences

Maastricht, 14th July 2013

B-EPH 3005 Thesis

Julia Schipperges

I6026198

University Supervisor: Inge Houkes

Placement Supervisor: Bernd Busen

Abstract

Background Stress is a huge influence on a person's mental health. People working in the

health care sector work in an environment that provides services every day at any given time

for physically and psychologically sick individuals. Caring for sick people is a demanding job

and internal as well as external factors can make working quite stressful, quite quickly.

Objectives This thesis will compare the experiences taken from interviews of nine hospital

employees from a specialist hospital in Germany to the results of a survey done by the same

hospital. We aim to identify possible stressors and health related issues influencing the mental

health of people working in the health care sector.

Methods Nine self-conducted interviews were coded using the techniques by Boeije (2010)

compared to the results of a hospital intern survey and discussed using the models of Karasek,

Kompier & Marcelissen and Bakker &Demerouti.

Results Time-workload imbalance, staffing problems and bureaucracy are causing most of the

stress in healthcare workers. As nearly a third of our interviewees reported health affiliations

attributable to work, which again influenced their mental health, we established that stress did

have influence on both physical and mental health.

Contents Abstract ...................................................................................................................................... 2

1. Introduction ......................................................................................................................... 4

1.1 The aim of the study ..................................................................................................... 5

1.2 Research Questions ....................................................................................................... 6

2. Theoretical Background ......................................................................................................... 7

2.1 The Job Demand-Control (-Support) Model ................................................................. 7

2.2 The Model of Work, Stress and Health ........................................................................ 8

2.3 The Job Demands-Resources Model ............................................................................ 9

2.5 The Research Setting .................................................................................................. 10

3. Methods ................................................................................................................................ 11

3.1. Study design ............................................................................................................... 11

3.2. Data Collection and Research Topics ........................................................................ 11

3.3. Population and procedure........................................................................................... 13

3.4. Data Analysis ............................................................................................................. 14

3.5 The 2011 Survey ......................................................................................................... 15

4. Results .................................................................................................................................. 16

4.1 The qualitative study ................................................................................................... 16

4.2 The 2011 Survey by the German specialist hospital ................................................... 22

4.3 The Comparison of the qualitative study and the 2011 survey ................................... 23

5. Discussion, Conclusion and Recommendations ................................................................... 26

5.1 Conclusion .................................................................................................................. 28

5.2 Recommendations and Perspectives ........................................................................... 29

5.3 Strength and Limitations of the Study ........................................................................ 30

Acknowledgements .................................................................................................................. 31

References ................................................................................................................................ 32

Appendix .................................................................................................................................. 33

Appendix 1 -Interview Questions (English version)......................................................... 33

Appendix 2 - Interview Fragen (German version) ............................................................ 34

1. Introduction

The issue of mental health has gained more and more attention over the last few decades.

Therapy methods and interventions are in the process of changing from industrialized to

community based care, as was demanded in John Bowis report on the Green Paper, Improving

the mental health of the population: Towards a strategy on mental health for the European

Union (European Commission, 2005) from 2006. The idea is to abandon heavy medication as

the only help and put social rehabilitation in the centre of care. Also, there is a shift from

secondary and tertiary prevention, to primary prevention of health problems on EU level.

However, mental disorders are still easily dismissed or mistaken for mood swings, 'just a bit

of stress' or labelling certain behaviour as simply 'crazy'. Discrimination and stigmatization

still hugely affect the public perception of mental health and mental illness in almost every

setting where it might occur. Mental disorders caused by stress can happen to everyone

though. Nonetheless, stress is a difficult term and has no clear definition, which makes it hard

to name exact characteristics and consequences, as it is used by lay people and professionals

alike in ever differing contexts (Pines & Keinan, 2005). When one encounters stress in

workplace settings however, it is hardly ever only stress. As people have to work harder,

faster and longer these days they are easily overwhelmed and stressed out, because they

cannot keep up with the workload or the wanted standards. Stress here origins from many

different sources, such as the draining or continuous strain of mental, emotional or physical

resources. This can lead to depression, even burnout, sickness absence and work disability

(Bakker & Demerouti, 2007). A widely used concept in stress is burnout. Burnout is the

consequence of a mental breakdown, a problem occurring from job stress (Pines & Keines,

2005). The definition of burnout that is probably most generally accepted and most widely

used was formulated by Maslach and Jackson (1986). They defined burnout as a syndrome

consisting of emotional exhaustion (i.e., depletion or draining of emotional energy or

resources), depersonalization (development of a negative, callous, and cynical attitude

towards the recipients of one’s services), and reduced personal accomplishment (i.e., the

tendency to evaluate one’s work with recipients negatively; it is believed that the objectives

are not achieved, which accompanied by feelings of insufficiency and poor professional self-

esteem). The reaction to job stress differs from person to person and there are various models

describing the relations between stressors, stress and long term consequences of stress, some

will be explained later on. It also depends on the job; each job has its own specific stressors

which can be mental, physical, or a combination thereof.

One sector that is particularly demanding, due to the seriousness of the business, the

emotional demand it places upon people and the high workload often experienced in this field,

is health care. The current study will focus on a specific group of employees in this sector,

more specifically hospital staff. A manifold of occupations can be found working in a

hospital; social workers, nurses, doctors, educational staff, therapists of different kinds and

managing personnel. As hospitals have to be kept running and functioning around the clock,

all of these occupations have at least a minimum level of stress to deal with. Nurses however,

according to Happell, Pinikahana and Martin (2003), experience stress quite frequently, which

hugely is down to frequent contact with patients in various circumstances. Especially in

nurses working in the field of forensic psychology, where interactions with partly aggressive

and even mentally ill patients regarded as dangerous are frequent, stress and burnout might be

presumably higher. Happell et al. (2003) came to the conclusion though, that nurses working

in forensic psychology experienced slightly lower levels of stress.

Another study by Ekedahl and Wengström (2007) among Swedish oncology nurses showed

various stress levels, depending on various personal and cultural factors. A study among

German surgical doctors, by Van dem Knesebeck, Klein, Grosse Frie, Blum and Siegrist

(2010) concluded that they were at a greater risk for psychological stress than other

occupations. Whether nurses have a significantly higher risk of stress than doctors or the other

way around, most studies identified that stress was present and a prominent phenomenon

among health care professionals. The current study will be conducted at a psychiatric facility

in Germany. We will focus on the following occupational groups: doctors/therapists, nurses

and social workers. These groups together present the majority of workers in closest contact

with the patients at this facility.

1.1 The aim of the study

Therefore, the first aim of this study is to get insight in the experiences of mental health

problems among the hospital employees in this research setting, as well as the determinants of

these health problems. The second aim is to formulate recommendations for the hospital, as to

how they can solve possible problems. We plan on achieving these goals with conducting

interviews among these occupational groups and comparing these to the hospital interne

survey from 2011.

1.2 Research Questions

Based on the above listed circumstances of our study, we formulated the following research

questions:

1. What are the experiences and attitudes of hospital employees with stress?

2. Are there any differences, regarding those experiences, between therapists, social

workers and nurses/educational staff?

3. What are the results of the 2011 survey?

4. How did the employees rate/remember the 2011 survey?

5. How do the experiences of the interviews match with the survey's results?

2. Theoretical Background

This chapter describes several models of job stress that will be used in this study; models that

will take several variables of the issue of stress in workplace settings into account. The model

of Job Demand-Control by Karasek (1979) is one of the most widely used models to explain

the balance between job demands and the decision latitude an employee has. Resulting

consequences can be learning or strain. The second model is the model of work, stress and

health by Kompier and Marcelisen (1990). It focuses on the influence of an individual's

coping abilities' influence on stressors, stress and health consequences. The last model is a

more recent model, developed by Demerouti and Bakker (2007). It is called the Job Demands-

Resources model, describing resources such as autonomy, support and feedback as a

regulating possibility for turning high strain into something positive, such as motivation and

other positive outcomes on organizational outcomes. The three models are widely used in the

research and provide a good overview of theoretical explanations of job stress and burnout.

The models will also be used to interpret the results.

At the end of this chapter a description of the research setting will be provided.

2.1 The Job Demand-Control (-Support) Model

One model of great importance to this paper is the Job-Demand-Control Model, developed by

Robert Karasek (1979). It explains the balance between psychological demands and decision

latitude as well as the resulting consequences, which are either a varying activity level or

certain degrees of unresolved strain. The more decision latitude is given by a high control job,

the better able is a person to learn, develop new skills or simply use it as motivation. If in that

case the demands are low, there is a really low possibility of experiencing strain from work, if

the demands are high, learning is even more possible. If the situation is reversed however, and

the demands are low as well as the control, the work situation is rather passive and may lead

to strain due to that. In case the demands are high and the control low though, strain resulting

in stress and adverse health outcomes is highly likely (van der Doef & Maes, 1999).

Applying this to hospital employees shows, that therapists/doctors for example usually

experience high control and high demands, while nurses commonly have low control but high

demands.

Figure 1. The Job Demand-Control model by Karasek (1979)

2.2 The Model of Work, Stress and Health

Another model quite relevant to this problem is the Model of Work, Stress and Health by

Kompier and Marcelissen (1990), which quite clearly shows the interrelation of stressors,

stress and health consequences. An individual’s coping abilities are here of uttermost

importance as they not only influence the reaction to a stressor but also the reaction to stress

and its consequences on one’s health. Kompier and Marcelissen divided stressors into four

categories: job content, working conditions, labour relations, and employment conditions. The

reactions to those stressors in this model are influenced by individual coping abilities and

might result in stress symptoms which are described as mostly physical (i.e., tension and

elevated heart rate) or cognitive behavioural (i.e., anxiety and irritability) by Kompier and

Marcelissen (1990). Again, coping abilities are what determine the stress outcomes (i.e.,

depression, fatigue and exhaustion).

Figure 2. The Model of Work, Stress and Health by Kompier and Marcelissen (1990)

2.3 The Job Demands-Resources Model

The Job Demands-Resources model from Bakker and Demerouti is a more recent model

developed in 2007. In his article Bakker criticizes missing components in Karasek’s Job-

demand-control model. In his model he tries to integrate resources as the missing component

significantly influencing the outcome of stress or high strain. He differentiates between job

demands, which can be work overload or frequent emotionally demanding interactions or

basically everything that requires sustained physical, emotional or psychological skills and

efforts, and job resources, which can be autonomy, feedback as well as support from

colleagues or superiors. When job demands are not dealt with correctly and so called

'performance protection strategies' have to be applied to somehow cope with demands, it

usually results in strain leading to negative organizational outcomes. Job resources, however,

can evoke the exact opposite. Career prospects make hard work less hard to bear and

continuous encouragement as well as support from colleagues give a feeling of appreciation

and underline an employee's significance to the company evoking positive effects on the

organizational outcome. (Bakker & Demerouti, 2007)

Figure 3. The Job demands-Resources Model by Bakker & Demerouti (2007)

2.5 The Research Setting

The psychiatric specialist hospital is part of a large psychiatric hospital network with ten

clinics and many more institutions, which is responsible for all of North Rhine-Westphalia. It

is the only of those ten clinics with an orthopaedic facility included in its hospitals structure.

Like all the other hospitals, this one is also self-maintaining with its own kitchen, carpentry

and IT department. Also, the hospital does a lot for its employees’ health wise. There are a

large number of courses offered, which include things like yoga, shiatsu massages, climbing,

quitting classes for smokers and several screenings as well, but also courses like conflict

management and time management are offered to help employees improving themselves. The

hospital has a large number of departments and wards, its children's and youth's psychiatry

being one of the largest in Germany. Adults are treated for any number of disorders and

diseases, with social rehabilitation and forensic wards, in inpatient and outpatient facilities.

Geographically, the hospital lies in close proximity to the Dutch border in a small German

town, with some outpatient departments in the neighbouring city. Its buildings are scattered

all over a large area and are surrounded by nature, which creates the atmosphere of a little

village. Several small chapels and community buildings complete that image. Founded in

1906 as a mental asylum/sanatorium with 800 beds, the clinic underwent a lot of changes in

its 108 years of existence. In 1940 the clinic had expanded so much that back then 2,500

patients could be taken care of. With the First World War additional military hospital wards

were added and the Second World War did not just pass by unnoticed either. From the

psychiatric wards of the clinic 1,500 patients were taken away and killed in the 3rd Reich.

Until the 1980’s the clinic was responsible for most of the neighbouring cities, then it was

relieved of most responsibilities. Today the clinic is responsible for roughly 380,000 people’s

mental health issues, has 730 beds (including the orthopaedic facility) as well as additional

outpatient facilities available and employs roughly 1,300 people. To mirror the variety the

hospitals size offers, we tried to include as many of the different specialities cared for as

possible in our interviews.

3. Methods

This chapter will introduce the design, data collection, population and procedure used to

conduct our study, the facts of the survey conducted in 2011 and the comparison of both.

3.1. Study design

The basis of this thesis is a qualitative study, in form of nine interviews conducted with three

nurses, three therapists/doctors and three social workers from different wards of a psychiatric

specialist hospital in Germany. The results of this qualitative study will be compared with the

results of a quantitative survey about employee commitment conducted in 2011 by an external

agency in the same facility.

3.2. Data Collection and Research Topics

Underlying all interview questions are certain key words or research topics that are crucial in

interpreting our interviewees answers. To structure the interview we decided on five main

categories with a total of thirty questions as our research topics (see Appendix 1).

General Questions

The first category was general questions. General questions included the time spent working

already, the motivation for taking that job and whether the interviewee was satisfied. The time

spent working and physical or psychological problems can easily be interrelated, as the longer

someone works in an office that is not ergonomically designed, or works standing and

walking a lot, back pains and other skeletal afflictions can be easily connected with the work

place. Also on-going psychological stress can explain breakdowns after several years of

enduring this kind of stress. On the other hand, such symptoms might have different reasons

when someone is fairly new to a job and that certain work environment. Motivation is another

important issue as it tells us more about the passion and enthusiasm underlying the

interviewees’ career choice, which again is important for the next topic of satisfaction. There

does not have to be external stress at all, when someone simply is not satisfied with his work

situation, that alone assimilated over years can be just as dangerous to one’s mental health as

actual stress caused by time pressure and immense workloads.

Questions about health

The second category straightforward inquires about the interviewees’ health; whether he or

she thinks that certain illnesses or simple afflictions can be related to their working situation.

We also asked the interviewees to give an approximation of how many sick leave days a year

they had.

Questions about stress

In the following category stress is the topic. To interpret answers as best as possible, we

wanted to gain an understanding of how the interviewees defined stress for themselves, so we

asked them to give a short definition. Following that definition, we wanted to see whether

they would differentiate between stress at work and stress in private. We also wanted to know

how they were coping with stress, dealing with stressful situation when they arose. What was

equally as important as their views upon stress was their ways of dealing with their patients’

stories and fates. In a facility like this, where there are a lot of tragic fates among the many

patients, the one or the other story might be really burdensome even to an experienced

employee. Stories where there are children or torn apart families involved are hardest and

might occupy one’s mind long after the working day was done. So it was essential to us to see

in how far the interviewees were affected by those fates and could deal with all of their

patients’ stories.

Questions about work

In this category we focus more on the work environment. The interviewees are asked to

describe and rate their work conditions and rate their relationships with colleagues and

superiors, as to give as an insight into their societal behaviour and situation. We also wanted

to know if the interviewees thought, they were under pressure to perform. Another important

topic in this category was responsibility. With that we wanted to look at the Karasek model of

Job Demand-Control. Responsibility can be seen as a form of control and demand in one, as a

higher position with more responsibility brings more tasks, increasing the demands, but also

more decision latitude or control. Therefore, too much responsibility can easily become

burdensome and stressful, as well as too little can be just as bad. The last two questions were

inspired by the 2011 survey results report, which introduced commitment as a result, and

questioned the interviewees’ commitment to the clinic and their patients. Although we

translated it in the German version of the interview, the idea was the same and remained.

Questions regarding the 2011 survey

In this last category we asked the interviewees to rate the questionnaire and its contents with

regard to health and whether there were changes they would attribute to the questionnaire.

The very last question gave the interviewees the opportunity to say what kind of changes they

would have hoped for to result from the questionnaire.

All answers were given freely in common German language. Selected quotes from the

interviews will be translated into English before usage in the results and discussion parts.

3.3. Population and procedure

The interviews population consisted of nine employees of the same institution. All employees

of the psychiatric specialist hospital were possible interviewees. To select the nine

interviewees we needed, we decided that we would focus on three occupational groups, being

nurses, therapists/doctors and social workers. We based our decision on taking the three

occupational groups that were working closest to the patient. So we chose the nine

interviewees purposively following suggestions. Each interviewee was interviewed

individually. Most of the selected interviewees were in their profession for quite some time

already. Seven of them held managing positions and thereby a significant amount of

responsibility not only for a large number of patients, but also colleagues. Therefore varying

levels of responsibility, experience and physical health, as well as the different wards they

were working on, defined the interviewees and determined their susceptibility to stress and

stress-related illnesses. To avoid confusion, the interviewees will be referred to by their

numbers in the following.

Table 3.1: Overview of Interviewees

Number Gender Occupation

Years

working Department

1 male Social worker 31 Addiction

2 male Nurse 21 Forensic

3 male Therapist 15 Outpatient

4 male Therapist 22 Social Rehab

5 female Nurse 11 Children's and Youth's Psychiatry

6 female Social worker 15 Children's and Youth's Psychiatry

7 female Nurse 28 General Psychiatry

8 male Social worker 17 Forensic

9 female Therapist 2 Children's and Youth's Psychiatry

3.4. Data Analysis

The interviews were transcribed verbatim. The transcripts were coded and thematically

analysed using the techniques described by Boeije (2010). The results from this analysis were

compared to the results from the 2011 Survey.

The focus of this comparison was on determining in how far the personal experiences of the

interviewees matched the results of the survey, and in how far stress influenced health and

happiness.

Qualitative Analysis

Boeije describes how qualitative analysis is based on two main activities, namely segmenting

and reassembling of data. The segmenting and reassembling is used to put data into concrete

findings. To come to those findings, coding is used. When coding data, one categorises

segments with a few short words, giving a very small summary of this segment. Different

coding techniques can be used. There are three in total: open, axial and selective coding.

When they are applied, a coherent pattern is formed and interpretation can begin. The three

forms of coding are usually used together as they build up on each other.

So we started with the open coding, which is usually the first step where either descriptive

codes (facts, events, etc.) or interpretive codes (meaning beyond the actual words, broader

meaning) are identified. In order to start the coding we identified fragments, as is the first step

to do before the content of the fragment can be described with a code. Following this process

we did the axial coding where we put the new codes into categories. Those categories will

then be identified as a main or a subcategory and clustered. Thereby, we reduced the number

of codes and put them into relation to each other and certain categories. We continued with

using selective coding to give meaning to the main and subcategories previously identified. A

core category was determined by looking at various variables, such as the frequency of this

category, the amount of subcategories and relations thereof to the most frequent category.

What we attempted to achieve by this was the identification of what the interviewee really

wanted to convey with their statements. As the final aim of our qualitative analysis, we put

the coded core, main and subcategories into relation to the research questions.

3.5 The 2011 Survey

As part of the quality management the hospital association, of which the psychiatric specialist

facility we focused on, is part of, employs an external agency to do a survey addressing every

employee of all its facilities. In the psychiatric specialist hospital we looked at, this concerned

roughly 1,300 employees, of which 50.4% filled out and returned the survey.

The survey is a sixteen page questionnaire with ten questions consisting of multiple sub-

questions, to be answered by ticking boxes from yes to no, to Lickert scales (very much to not

at all), one open question and a final rating of the survey itself. The first ten questions covered

the employees views on information flow, their working conditions, the behaviour of the three

management levels (direct superiors, head nurses, clinic management), employee support and

development, employee involvement, organisation of resources and collaboration of different

patient-focused occupational groups, as well as a few personal characteristics (e.g.: time of

employment, age-group, gender and occupational group). The last question gives the

opportunity to voice criticism, advice, proposals or suggestions.

Following the return of the survey and its evaluation, the agency released a small catalogue of

the results, which was partly discussed on some, but not all wards and departments. The

results from the survey will later on be compared to the experiences from the interviews in

section 4.3.

4. Results

The results section will present our findings of the qualitative study, the 2011 survey and the

comparison of both. In order to give this section an organized structure, we decided on

trisecting it and dividing it further by using the respective research questions; the sections

being the qualitative study with research questions 1 and 2, the 2011 survey with research

question 3 and the comparison featuring research questions 4 and 5.

4.1 The qualitative study

From the nine conducted interviews we were able to conclude a number of key issues/themes

that played a huge role in causing stress and unnecessary trouble in the interviewees work life.

We identified those issues to be time pressure in relation to workload, shortages of personnel

and bureaucracy.

In order to assess the current health statuses of our interviewees, we asked them to estimate

sick leave duration in days and name any physical complaints they had and would attribute to

their work. When comparing answers on estimated sick leave duration, we noticed that nurses

reported the highest number of days, ranging from 5 up to 14, while therapist came close with

5 to 10 days. Social workers reported the lowest duration of estimated sick leave with only 2

to 6 days. Evaluating the answers to the question of physical complaints attributable to work,

only three interviewees were able to say that they had no physical complaints resulting from

work, whatsoever. The most often reported complaint was backache. Four interviewees

mentioned it, two being nurses and the other two being therapists. Interviewee two, a nurse,

and interviewee three, a therapist, even recounted having had spinal disc hernias before.

Among the nurses, interviewee two also said he was having high blood pressure lately and

interviewee 7 mentioned sleep disturbances, from which she was suffering immensely. The

therapists further recounted having migraines (Interviewee 4) and worsening allergies, as well

as newly developed asthma (Interviewee 9). Of the three social workers however, no one

reported anything specific. Only interviewee 6 said that she had had a hard time during the

first two years of working for the clinic, as there was no one there to provide her initial

training and she had to find out herself, but did not mention anything more specific.

While migraine, sleep disturbances and also high blood pressure are quite likely to be a result

of stress, backache, asthma and allergies however are most likely a result of unhealthy work

environments possibly in combination with stress.

1. What are the experiences and attitudes of hospital employees with stress?

Several questions in the interview were aimed at gaining an answer to this question. Most

important however, were the definitions we asked our interviewees to give. Therefore, stress

was defined nine times and each definition differs somehow, naturally, most of them however

centred on the same concept, being an unsolvable situation, a conflict without obvious

solution. There are as many internal as external factors attributing to stress and each

individual reacts differently to them. Some said that there were different kinds of stress.

“I divide stress into productive and unproductive. If there is a lot to do, then that's productive stress, I

don't mind it and it's more of a raison d'être. It gets difficult when at times when there is a lot to do,

issues posing a personal burden, personal conflicts come along and overshadow work itself. That's

what I feel is destructive stress.” (Interviewee 4, Therapist)

Interviewee 4 identified most of his stressors to be unnecessary bureaucracy in form of

occupancy rates as judgement criteria of a successfully run ward, instead of the actual quality

of care offered to the patients. Also, like almost all other interviewees he mentions a problem

in staffing, which in this case is due to the high average age of the employees in his

department, where new and young employees would be needed. Other definitions focussed

more on problems to be solved as the reason for stress. Unsolvable situations or conflicts and

situations they cannot escape directly were described. The following citations are from the

two social workers and one nurse, giving quite similar definitions.

“I would define stress as an unsolvable situation. A situation I cannot avoid and have to bear through.

It can be problems with patients or internal conflicts of the company. Things that cannot be solved

right away but have to be suffered through.” (Interviewee 1, Social worker)

“Stress is the conflict with unsolvable tasks that are quantitatively or qualitatively too difficult, too

much.” (Interviewee 2, Nurse)

“Stress is when I have a dead-end situation and cannot change anything about it, because I cannot

change other people.” (Interviewee 6, Social worker)

Interviewee 3, 7 and 8 also gave similar definitions with the focus on not being able to handle

situations where there is too much work to handle alone. This view was represented in all

occupational groups. Their stressors were also quite similar as two of them mentioned

bureaucratic tasks as hindering and all of them named staffing issues as a main stress causing

problem.

“I am stressed when there are too many things to be done at once, which are regarded as equally

important. (When things cannot be planned)” (Interviewee 3, Therapist)

“Stress to me is when there is more to do, than I am able to handle.” (Interviewee 7, Nurse)

“Stress is external pressure you cannot compensate for with your own motivation. That's stress to

me.” (Interviewee 8, Social Worker)

The definition of the only female therapist in our sample was quite remarkable, as it regarded

stress specifically as a result of failing to deal with stressful situations.

“I am stressed when I get the feeling that, although I tried to structure and prioritize the problem and

adapt to it as best I can, I am unable to handle it quantitatively and qualitatively; when my capability,

efficiency and performance aren't enough to handle the current requirements.” (Interviewee 9,

Therapist)

Her stressors were similar to the other interviewees’ stressors, but she was the first to actually

mention a lack of guidelines and regulations on her position, so essentially too little

bureaucracy as a main reason for her kind of stress. She is also among the four interviewees

reporting pressure to perform in one way or another. External and internal expectations were

most bothersome to her, as they created a kind of pressure to perform that was hard to keep up

to. While interviewee 1 described it as an economical pressure, interviewee four described it

as pressure due to lacking personnel and interviewee 7 said it was due to miscalculated

budgets not matching their overly high occupancy rates. Obviously there are many reasons for

pressure to perform, but only four of nine employees reported that there was some kind of

pressure to perform at all.

What we were able to deduct from the definitions is that stress experiences are highly

different and very personal, even though some definitions were similar, none were exactly

alike. Stressors however, were quite a bit more similar, as seven out of nine interviewees

named staffing problems, so too little personnel as a major issue and five mentioned

bureaucracy. Too much work was mentioned by interviewees 4 and 8, and lack of personal

space for the employee was mentioned by interviewee two and seven. Interviewee 3 was the

only one who mentioned societal stigma as a problem causing factor to his work, as he had

worked on a closed psychiatric ward before and had made many negative experiences with

relatives of patients accusing him of unnecessarily confining their loved ones. He reported

that it often made his work harder and caused unnecessary stress, when he had to deal with

those relatives on top of their sick loved one, who actually wanted and needed help and

attention.

Following the definition and the identification of the stressors, the interviewees were asked

whether they would make a difference between stress at work and in private. A distinction

between private and work stress was made by all interviewees, except interviewee 9.

Interviewees 6 and 8 even explicitly said that private stress was definitely worse than stress at

work. Most however agreed that work stress was easier to leave behind and keep at work

where it belonged when the day was done. It would have to be really extreme to still bother

them after work, which was another point which was hugely similar. Not all of them said that

it was easy to just switch off their minds and forget about their patients after work, though.

Interviewee 1 described it as a learning progress that came with experience and, as well as

interviewees 2 and 5 reported that they were completely unaffected by their patients fates and

left their work at work. While interviewees 4 and 8 said that they were hardly affected and

only sometimes still occupied with their work after hours, interviewees 3, 6, 7 and 9 all agreed

that it depended on the kind of stress or fates experienced whether they would be affected and

could not let go even after work. Interviewee 3 recounted such a story, where one of his

patients had lost his son, because he fell asleep on the lawn of a public swimming pool, while

the boy, who was unable to properly swim yet, drowned. This story had hit home, as he

himself has children that age and could only imagine what it would do to him, to lose one of

them.

"I was really touched. Even now just talking about it makes me... No one is that cold, not to be

touched by this. Especially because I have children of my own and my youngest son is

approximately the same age that my patient’s son was in and I would be devastated, too."

(Interviewee 3, therapist)

When it came to coping with stress answers were quite varied but all agreed that talking was

the key to dealing with difficult issues. Doing sports was mentioned by interviewees 1, 2, 3

and 9, and hobbies and other activities being distracting were quite popular as well

(Interviewees 2, 3, 4, 8 and 9). Team work was also mentioned by three of the interviewees

and it was noted that good team work was essential to minimizing stress and resolving

stressful situations quickly and adequately. Calming down, experience and using the drive

home or the walk from one place to another as methods to reorganize and calm down were

mentioned as well.

Even though every one of the interviewees was able to identify some factors in their work life

causing stress it is astonishing how none of the interviewees liked their jobs any less, or were

less loyal about their employer due to that. All of them answered positively when asked

whether they were satisfied with their job, although interviewee seven mentioned that, while

circumstances got worse and made it harder from day to day, she loved her job nonetheless.

“I still love my job as I always have. I like being a nurse, I also like being a nurse in a psychiatric

facility, I really do. But when you are working with two or three other colleagues and you have

twenty-seven patients of which four have to lie in the hallways, it is very unrewarding and

dissatisfying, it makes you feel helpless.” (Interviewee 7, Nurse)

2. Are there any differences, regarding those experiences, between

therapists/doctors, social workers and nurses/educational staff?

Generally we cannot say that there were obvious or highly surprising differences between the

three occupational groups. What can be said is that nurses tend to stick out from time to time,

and have least in common with social workers. Therapists also have more in common with

nurses than with social workers, but do not lack similarities with them either. Only one

difference was striking and that was the lack of physical complaints reported by social

workers. From all six nurses and therapists only one nurse also reported not having any

physical complaint she would attribute to her work. As already mentioned above, the only two

definitions slightly similar within occupational groups were given by Interviewees 1 and 6,

who both are social workers. All other similar definitions cannot be ascribed to any kind of

pattern regarding occupational groups. Bureaucracy was only mentioned by nurses and

therapists as an issue making their work life unnecessarily complicated. It was mentioned as

frequently being the reason for time-workload imbalance, as paperwork has certain deadlines

but caring for the patients is more important and often leaves little time for said paperwork.

The staffing issue was a problem, therapists and nurses have in common, as all therapists and

all nurses brought it up, but only one social worker mentioned it. One point that social

workers and therapists have in common is the professional autonomy they often enjoy, which

makes their working days less monotonous and leave room for more creativity.

“I enjoy a relatively high professional autonomy and at the same time have a direct supervisor with

whom I work well together and have a trusting work relationship and from whom I receive the

appreciation and support I need.” (Interviewee 4, Therapist)

“On the one hand I have the possibility, as a therapist, to freely make decisions on my working hours,

as well as the things I prioritize and regard as most important for the families, and to be creative as to

how I deal with the family and children talking sessions.” (Interviewee 9, Therapist)

“[…] otherwise I believe I have quite a big scope of action, where I can work independently.”

(Interviewee 6, Social worker)

Personal space however, was only mentioned by nurses, as they do not have their own offices,

not even head nurses, as opposed to social workers and therapist, who all have their own

offices. They mostly only have one common room and one office for all of them on a ward.

When it comes to rating the 2011 survey only two of the nurses and one therapist were clearly

positive and found it necessary and useful. Among the other two therapists, interviewee 9,

while generally thinking that it is good to have an employee survey does not like the concept

of surveys, as she found it hard to convey her actual message with it and not be

misunderstood; Interviewee 3 seemed quite disappointed in the survey as he feels his

complaints and comments are being ignored and has not really noticed any kind of change

following the surveys. The social workers were more reserved when rating the survey,

generally liking the idea and practicality of it but not seeing any real effects and questioning

its representativeness. All nurses mentioned anonymity but in hugely differing ways, as

interviewee 5 did not think it was anonymous enough, interviewee seven thought of it as

unnecessary, as she believed in speaking her mind and sticking with it, whereas interviewee 2

only mentioned anonymity as being a good characteristic of the survey generally.

One quite apparent difference we were able to see was that, compared to almost all other

interviewees, we were unable to identify an underlying message in the social workers

interviews. Interviewee 9 emphasized several points such as her job guidelines being to

unspecific and not having a budget for therapeutic materials; Interviewee 7 really wanted us

to know that her ward was completely overcrowded and that things only got more

bureaucratic and complicated, but that they were doing a good job after all. While nurses as

well as therapists had many points that were not going well, it seemed that social workers had

almost nothing to complain about. Therefore, apart from one or two similarities, we only

found that social workers, unlike the two other occupational groups, did not report physical

complaints attributable to their work. They were also generally more relaxed and reserved in

their answers, as well as missing underlying personal messages to convey during the

interviews, compared to most other interviewees.

4.2 The 2011 Survey by the German specialist hospital

In the fall of 2011, over the duration of four weeks, the third employee survey in form of a

sixteen page survey took place. The survey addressed all employees and was done by an

external agency, which was hired by the association of psychiatric clinics the specialist

psychiatric hospital we focused on, is part of. With a response rate of 50.4% the previous

year's rates were surpassed.

3. What are the results of the 2011 survey?

The main results were an increase in job satisfaction overall, which was most noticeably

increased in nursing and educational personnel. Commitment was another outcome measure,

which did not actually increase or decrease between the 2011 and the previous survey 2008.

Looking at the occupational group’s commitment however, we can see quite interesting

differences between nurses, therapists and social workers, though. As can be seen in figure 2

below, Social workers have the highest middle-level commitment, and the lowest low-level

commitment. Nurses, here in a group with other educational staff, are closest to the overall

situation. The highest low-level commitment can be seen in therapists, who also have a

comparatively low high-level commitment. Remarkable is that therapists have the same

middle-level commitment as social workers, whereas social workers and nurses share their

high-level commitment rate.

Figure 4. Commitment Table by occupation

4.3 The Comparison of the qualitative study and the 2011 survey

The comparison of our qualitative study and the 2011 survey is the main focus of our study.

We want to find out if the survey's results match the results of our interviews or if there are

huge differences.

4. How did the employees rate/remember the 2011 survey?

Ratings can be described as quite different and trends could not actually be ascribed to one

specific occupational group, except for more indifferent and mild ratings from all the social

workers. They generally liked the idea of it but interviewee 1 specifically said that it was not

representative enough.

"(...) I did it, because I should, or rather was supposed to, of course it was officially voluntary. But I

am not really open towards things like these, because I can much better feel the current mood and

work climate and that's much more informative and meaningful than a survey." (Interviewee 1, Social

worker)

None of the social workers were able to remember if all important issues were covered and

interviewee 1 and 8 were mostly disappointed by not seeing any changes, whereas

interviewee 6 noticed that there recently had been a few additions to the number of social

workers. The nurses were not all on the same page, while interviewee 2 and 7 really liked the

survey and interviewee 2 even noticed changes, such as more transparency and a motivation

in superiors to do more for their employees, interviewee 5 did not like it at all. She was not

convinced that it was actually anonymous and found the survey to be too broad and general as

well. Among the therapists interviewee 4 and 9 generally liked the idea of a survey as such,

interviewee 9 however questioned the use of a survey as she found it hard to really get her

point across.

"It's not about me not wanting to say what I think, but that I am afraid of not being understood, being

misunderstood because I wrote it like this." (Interviewee 9, Therapist)

Interviewee 3 had the most negative opinion of all the interviewees, saying that it was actually

useless as there never had been changes following such a survey even after repeatedly

mentioning things in all three surveys and independently. He also mentioned that it probably

just was something the clinic had to do to keep in line with the associations quality

management.

The survey overall, was not unwelcome. We had two quite negative ratings, three very

positive ones and four that were not opposed to the survey in general but have been

disappointed so far.

5. How do the experiences of the interviews match with the survey's results?

In section 4.2 we introduced commitment as the outcome measure of the 2011 survey. As it

was also part of our interview, we will compare the results of both.

The results of the 2011 survey showed similarities in the middle-level commitment of

therapists and social workers and that the nurses' commitment was fairly equally distributed

on all three commitment levels. What we were able to see in the interviews was that neither

nurses nor therapists were less than mildly committed. Answers ranged from highly

committed to commitment due to long time and a distinction between the clinic as an

employer, to whom there was a kind of commitment and the association of psychiatric

facilities, to whom there was no kind of commitment at all (Interviewee 3). The social

workers' answers were quite different though. Interviewee one called it corporate identity,

referring to the long time he'd been working for the clinic and that the clinic actually cared for

its employees.

"After almost 25 years one certainly developed something like a corporate identity, right? It hasn't

always been this way, but developed over the years, seeing as our employer certainly does something

for us, also with regards to advanced education, which is clearly regulated." (Interviewee 1, Social

worker)

Interviewee 8 was the only one that actually used the term commitment, even in the original

interview, which was conducted in German language. He described his commitment as very

high. The last interviewed social worker, interviewee 6 said she was not feeling committed to

the clinic at all.

"I am working here. I do my job, which I enjoy doing and I like coming here every morning, but am I

committed to the clinic? I work here, nothing more." (Interviewee 6, social worker)

We also questioned the interviewees about their commitment toward their patients and were

happy to hear that among all three occupational groups a high commitment was evident.

While therapists were not all as enthusiastic as the nurses, who reported a very high

commitment, they were still highly committed and felt a deep responsibility, which the social

workers shared as well.

"Yes, they are everything to me. They are extremely important to me. I am attached to a lot of them,

because I have known them for a very long time already." (Interviewee 7, Nurse)

"Yes, I feel committed, I am responsible for them. Psychologically sick individuals have no actual

lobby, no forum to be represented by. There are often ostracized by other patients." (Interviewee 4,

Therapist)

"They are important to me. It's not always easy, but I am always happy when they've achieved

something. That's where I feel committed and responsible for helping to bring along such

achievements." (Interviewee 6, Social worker)

All in all we were able to establish that for some interviewees stress had a huge impact on

their health and less so for others. Nevertheless , we were unable to find even one interviewee

who did like his job less and was not committed to his patients first.

5. Discussion, Conclusion and Recommendations

In this section we will discuss our results and analyse them by using the various models of job

stress introduced in section 2.

The mental health of hospital staff is hugely affected by stress and can even result in physical

symptoms as we were able to see in a few of our interviewees. However, it did not influence

their passion for their jobs, their commitment to their patients or their commitment to the

clinic at large.

Not every interviewee did have complaints and was experiencing stress as such. Those,

however, that were seemed to agree more or less on the core issues. And at the heart of the

matter it was certainly the staffing problem that was hardest to deal with. It was also the

underlying cause for almost all other stress causing factors. A time-workload imbalance is

caused by too much work of course and too little time. Usually however, if there are enough

colleagues, no one should have trouble doing their amount of work in the prescribed time,

usually. When there are missing colleagues though, fewer people have to do the same amount

of work still.

If we take the situation interviewee 7 told us about, where she and only three more colleagues

are responsible for as much as twenty-seven patients and she herself, being head-nurse had to

carry even more responsibilities than only the usual amount of any other nurse, then we see

how stressful situations evolve with too little personnel for too many patients. Her situation is

also intensified by her physical complaints and makes her the one interviewee we thought

most endangered by stress and possible further consequences. Applying the model of work,

stress and health (Kompier & Marcelissen, 1990) to the situation of interviewee 7 shows us,

that her work clearly contains stressors she cannot compensate for herself. Those stressors

lead to stress symptoms, such as tension and irritability, which she described of having, and in

return cause stress outcomes such as the sleep disturbances interviewee 7 reportedly suffered

from.

Missing personnel can, of course, sometimes simply occur due to colleagues being sick,

something that cannot be entirely prevented. The situation will eventually return to normal

and time and workload will match up again. When there is not enough staff on the ward to

begin with though, the problem is much bigger and can lead to severe consequences in the

end. The solution would be hiring additional personnel, and while that seems to be easy

enough, financing is surely the crux of the matter, which is why we would go as far as to even

identify economic structures in the health care sector as the underlying cause of almost all

stress causing factors we came across in this study so far.

Another interviewee that struck us as highly interesting as well was interviewee 2. He told us

a bit more about his work life, as he just recently had gone through a crisis, as he called it. It

essentially changed his views and his behaviour regarding his work. While he was always

very confident in his abilities and enjoyed his work immensely, over a longer period of time a

certain tension build up and in the end led to a crisis that continued for quite some time. In

retrospect he attributed the crisis to a previous bad relationship, which led him to overly

engage in his work and lose focus, where he reportedly experienced no stress at work at any

time, whereas he encountered it in his private life frequently. Then, adding to his already bad

situation, one day he went through a very horrible experience, he said. He did not elaborate on

it any further but said that, at that time he was not sure if he could ever work again.

"[...] I transferred to another addiction ward and there I made a horrible experience, after which I

thought I could never work again, never work as a nurse again." (Interviewee 2, nurse)

The incident combined with the build-up tension led to a breakdown and only with the help

and support from friends, family and the clinic he was able to continue working. Following

this experience he came to a closed forensic ward, on which he currently works. He still

enjoys his work immensely and is still fascinated by his work and his surroundings every day.

Were we to apply a model to his experience, we think that the job demands-resources model

by Bakker and Demerouti (2007) fit best. The essential part to this model is the jobs'

resources given that oppose the demands. In interviewee 7's case it were external factors,

being a bad relationship that caused him to no longer be able to deal with his jobs demands,

leading to an increase in strain. The organizational outcome in his case, luckily, was support

that helped getting him back on his feet.

Another interviewee’s situation applicable to this model is that of interviewee 9. Her main

problem is her unspecific job description. As the head therapist on her ward, she has a lot of

responsibility but also enjoys a lot of professional autonomy. The model lists autonomy as a

job resource, as interviewee 9 however does not know, where this autonomy ends, strain

increases and might end up leading to severe consequences. While she is still fairly new to

that position, as she has only been there for about two years now, additional job demands and

stressors (staffing problems, high expectations from colleagues and patients, and also

bureaucracy) only add to her strain and might worsen her situation.

The Job control-demand model by Karasek (1979) is best explained by comparing

interviewee 4, a male therapist to the experiences of our only female social workers first two

years of employment (Interviewee 6). While interviewee 4 perfectly fits into the high demand,

high control group of Karaseks model, as he is head of the department he works in and carries

a lot of responsibility, but also professional autonomy, interviewee 6's job offered little

control and very high demands in the beginning. She recounted having very tough two years

in the beginning when she took the job, as there was no one providing her initial training. She

had to work it out alone and held little control over her situation, while demands were high, as

colleagues needed her to know what she was doing. This combination resulted in a continuous

desire to quit all through the first year.

"During my first year, I repeatedly had the desire to just quit. But I worked it out, I struggled through.

I am perfectly fine now, have been for years." (Interviewee 6, social worker)

Interviewee 4 on the other hand is highly interested in his colleagues' opinions and is very

motivated to try a lot of things, introducing creativity to his workplace. Today, interviewee 6

also enjoys her job a great deal. While she her work still offers high demands, she has control

over her it know and enjoying a lot of professional autonomy and room for creativity, she

experiences no strain anymore. Instead she is highly motivated and interested in seeing her

patients succeed.

5.1 Conclusion

The interviewees we met work in an interesting and maybe difficult environment and their

patient clientele outwardly differs from any usual hospitals patient as there are no physical

injuries or wounds to treat. That however makes their work so special and important, as

treating wounds we cannot see can be much harder. Maybe being around patients such as the

ones they care for made them a little harder, or simply better able to deal with tragedies.

Physically ill patients can have equally sad and devastating stories but mentally ill patients

and their loved ones already have a hard time understanding that they are sick and need help,

and helping surely doesn't get easier when you first have to convince someone that they do

need it.

Nevertheless, even our interviewees are not prone to the effects of stress and the stressors

around them. They suffer from symptoms one would most likely find in a doctor or nurse or

social worker occupied in any other somatic hospital as well. As Happell et. all. (2003)

already established amongst his findings, nurses working on forensic psychiatric wards

experienced lower levels of stress than expected. While we had only one interviewee working

in such an environment, who also reported that his work on that specific ward wasn't stressful

actually, we still cannot say, that the psychiatric specialty of the hospital they work in has a

greater or lesser impact on their mental health.

5.2 Recommendations and Perspectives

As we identified several stressors, making our interviewees work life unnecessarily more

complicated and even affecting their health, we would recommend the removal and further

prevention of these. The regulation of the staffing problem, as it seemed to be at the bottom of

most other problems, would be the best point to start. Even the addition of a temporary part-

time position can already help in avoiding time-workload imbalances until a more structured

method or process is found to deal with the amount of work at hand. Time-workload

imbalances were reportedly caused by staffing problems and also bureaucratic tasks could be

handled more timely, if more staff was available. Here again, no full-time position needs to be

added. A part-time help in form of a secretary to aid the therapists in writing their reports

would already be immensely helpful in preventing trouble due to overdue reports and

physician’s letters for continued treatment. Another important issue, if only mentioned by two

interviewees is missing personal space. Having lounges for employees be made available on

every ward, where they can take a break and get away from work for a minute or two would

be a start. Installing lockers as well as a mailbox for every employee without an own office

space to leave messages for colleagues in and store personal items would not only make them

feel more appreciated by their employer but also improve cooperation and teamwork amongst

colleagues. While we know that any kind of change costs and that money is not easily

available all the time, the changes we proposed are not all highly expensive and can be seen

as a valuable investment in the health and happiness of the hospitals employees.

What would be interesting for future studies would be to look into specific stressors and

investigate in how far they are responsible for causing stress. For example the proposition we

made earlier of economic structure being the underlying cause of many of the stressors we

identified. Taking bureaucratic structures in Germany as an example, it would be interesting

to see what kind of influence the improvement and simplification of those structures, as well

as the elimination of unnecessary paperwork and having clearly defined responsibilities would

have on a health care employees work life.

5.3 Strength and Limitations of the Study

As small a number as nine interviewees can never appropriately represent as big a number as

1,300. It however gives us a fairly good overview of the three occupational groups mainly

involved in patient care, and a further perspective of nine different people each in different

work environments, although working at the same institution. While the sampling was

purposively we tried to create a group of interviewees of mixed gender and representing all

three chosen occupational groups equally. We were unable to take the duration of time spent

working into consideration as we only had one interviewee that had been working for less

than 10 years. Avoiding selective responses or deliberately embellished answers was not

prevented by leaving the interviewees unaware of the purpose of the interview, as we had to

inform them beforehand, as was stipulated by the hospital.

Nevertheless, we think that we were able to select a quite diverse sample of participants. We

tried to select people from almost all psychiatric departments, and always from different

wards, and while they may not be a big sample, they were an interesting group and helped us

gain an insight into their work life and how they dealt with stress.

Acknowledgements

At this point I want to express my appreciation to my thesis supervisor, Inge Houkes, for all

the time, work and help she invested in me and this bachelor thesis.

I also want to thank my placement supervisor, Bernd Busen, for the time, guidance and help

he invested in me and the great experiences I was able to gain at my placement institution.

Another very special thanks goes to my nine interviewees, as they took the time to share their

stories with me and answer my long list of questions.

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Appendix

Appendix 1 -Interview Questions (English version)

General Questions:

1. How long have you been working in this job?

2. What motivated you to take this job?

3. Are you satisfied in your job?

Questions regarding health:

1. Do you have any physical complaints, which you would ascribe to your work

situation?

2. How many days a year are you sick on average? How many in the last three years?

Questions regarding stress:

1. How would you define stress?

2. How do you experience stress generally and in your work and private life?

3. When do you experience the most stress?

4. How do you usually cope with stress?

5. How much do your patient’s situations affect you?

6. What types of cases affect you most?

7. How much of your work do you "take home" with you?

Questions regarding work

1. How would you describe your work conditions?

2. How are the relationships with your supervisors?

3. How are the relationships with your coworkers/colleagues; is there trouble occasional?

4. Do you have much responsibility?

5. Do you want less/more?

6. Do you experience much pressure at work?

7. Do you have enough variety or would you describe your work as monotone?

8. Are you limited on resources and facilities, or is there enough funding for your ward?

9. How would you describe your commitment to the clinic?

10. How would you describe your commitment to your patients?

Questions regarding the 2011 Survey:

1. How would you rate the 2011 Survey and the one from last year?

2. Did the survey cover everything that was important to you?

3. If not, what did you miss?

4. Did the survey cover health good enough or just briefly?

5. Did the survey change anything for you?

6. What changes would you have hoped for?

Appendix 2 - Interview Fragen (German version)

Allgemeine Fragen:

1. Wie lange führen sie ihren Beruf schon aus?

2. Was war für Sie motivierend diesen Beruf zu ergreifen?

3. Sind sie zufrieden mit ihrem Job?

Gesundheitliche Fragen:

1. Haben sie irgendwelche physischen Beschwerden, von denen Sie glauben, dass sie

durch ihre Arbeit verursacht wurden/werden?

2. Was schätzen sie, wie viele Tage sie durchschnittlich im Jahr krank waren?

Stress Fragen:

1. Wie würden Sie Stress definieren?

2. Wie empfinden Sie Stress auf der Arbeit und privat?

3. Wann empfinden Sie den meisten Stress?

4. Wie gehen Sie normalerweise mit Stress um oder versuchen damit umzugehen?

5. Wie sehr nehmen die Schicksale ihrer Patienten sie mit, speziell bei besonders

schweren Fällen?

6. Welche Fälle treffen sie am meisten?

7. Wie viel ihrer Arbeit "nehmen sie mit nach Hause", im Sinne von: wie sehr beschäftigt

sie Ihre Arbeit noch nach dem Feierabend?

8. Empfinden sie Stress zuhause/privat anders als auf der Arbeit?

9. Wenn ja, wo mehr und warum?

Fragen zur Arbeit:

1. Wie würden sie ihre Arbeitsbedingungen beschreiben?

2. Wie würden Sie ihr Verhältnis zu ihren Kollegen beschreiben?

3. Wie würden sie ihr Verhältnis mit ihren Vorgesetzten beschreiben?

4. Tragen Sie viel Verantwortung?

5. Würden sie mehr oder weniger Verantwortung wollen?

6. Empfinden sie (viel) Leistungsdruck an ihrem Arbeitsplatz?

7. Ist ihre Arbeit abwechslungsreich oder eher monoton?

8. Haben sie nur limitierte Mittel und Räume zur Verfügung, oder sind die Bedingungen

zufriedenstellend?

9. Wie sehr fühlen sie sich der Klinik gegenüber verpflichtet?

10. Wie sehr fühlen sie sich ihren Patienten gegenüber verpflichtet?

Fragen zur Mitarbeiterberfagung 2011:

1. Was halten Sie von der 2011 durchgeführten Mitarbeiterbefragung?

2. Hat diese die Bereiche abgedeckt die Sie wichtig fanden?

3. Wenn nicht, was vermissen sie?

4. Sind die Fragen aus dem Fragebogen gut genug auf ihre gesundheitlichen Belange

eingegangen, oder haben diese die nur "angekratzt"?

5. Hat sich denn auch etwas für Sie persönlich geändert?

6. Welche Veränderung hätten Sie sich gewünscht?