Determining the characteristics of a mental supportive workplace according to female hospital staff in one of Tehran hospitals: A qualitative study.

BACKGROUND: Health-care workers are exposed to complex types of health and safety hazards. A high percentage of hospital staff in Iran are women, who in addition to heavy and stressful hospital work, also carry the burden of the family roles. It is in these circumstances that creating a supportive environment for women is of particular importance. Accordingly, this study is designed to determine the characteristics of a mental supporting work environment in the workplace from the perspective of female hospital staff.
MATERIALS AND METHODS: This study was performed by a qualitative method and content analysis approach. Sampling was purposive and 26 women working in different wards of this hospital were included in the study. In this study, women with maximum diversity in terms of age, work experience, and employment ward were selected. The main method of data collection in this study was a semi-structured interview. Interview texts were extracted and divided into meaningful units. To validate and confirm the results plus accuracy of the research, the criterion of data validity or data credibility, admissibility, data accuracy, verifiability, reliability, and transferability were used.
RESULTS: Through the data analysis, 58 primary concepts with the same features were classified into 10 subcategories. Then, based on common features at a more abstract level, they were converted into four main categories including job stressors, women's stress management, providing women's psychological-job satisfaction, and women's work-life balance.
CONCLUSION: Creating supportive work environments for women, especially those operating in workplaces such as hospitals, which brings a lot of work pressure and workload for them, can be an important policy for organizations and hospital work environments. Copyright:

Introduction

The health-care department is one of the largest sources of employment worldwide, which is exposed to a wide range of health and safety hazards, from biological hazards to ergonomic and psychosocial factors.[1] As one of the characteristics of a healthy organization, the physical and mental health of employees should be considered by management as much as its generation and productivity.[2] One of the aspects of health in the workplace is paying attention to the mental health of employees, which can be affected by several factors.[3] Social support, imbalance in payments for work performed, unusual working hours, conflict of roles, family status, and work-life balance are important predictors of mental health in employees of various organizations.[4] Work environments such as health care centers are also more stressful than other workplaces, and recent studies have shown that psychological factors at the workplace are more influential than factors such as physical factors.[5]

Working in health workplaces such as hospitals are among the jobs that are affected by various factors due to the responsibility of health and treatment of patients.[6] Ignoring work pressures and stresses in the staff of medical units can have consequences and impose high therapeutic costs on the health-care system of organizations.[7] Furthermore, health-care workers in hospitals, including doctors and nurses, are at higher risk of depressive disorders than the general population. The dangers of long working hours of doctors, nurses, and interns have been proven.[89]

What needs to be considered more carefully nowadays is the greater presence of women in the workplace, knowing that about half of the working population are women. Attention should absolutely be paid to their health specifically in the workplace by the organization. Women with 8 h of daily work are at a higher risk for health disorders.[10] Work has generally a positive impact on the health of both women and men as well as the health of households, communities, and economies. However, physical and mental health risks also affect them. Although work is an important part of women's lives and can have a positive impact on their health, the stress of overwork in women can affect their mental health as well as their short-term and long-term absences.[111213] Although women have made great strides in their careers, their responsibility to the family has not diminished. They must take care of their family responsibilities in addition to their official work. One of the most prominent challenges that every woman must face in her life is the balance between work and life.[1415] Although men spend more time in business relations, working women are more likely than men to experience work-related stress due to having multiple roles, and the psychological effects of this issue on women are greater than men.[16] A high percentage of nurses and people working in medical centers in Iran are women who in addition to heavy and stressful nursing work, face pressures such as high workload, exposure to patient suffering, patient and companion violence, night work, etc., while also carrying on family roles.[17] With exposure to such stressful and anxious situations, social support and the creation of a supportive environment can mitigate the effects of these pressures.[18] Exposure to stressors in the workplace such as hospitals will have a greater and different impact on women.[19] Due to the numerous roles that women play in society and the family, especially in societies such as Iran, it creates conflicts in their roles in the workplace, society, and family. This conflict of roles and stressors that exist in the workplace, especially in the hospital, can cause psychological and physical harm to them. Although many studies have been done on the impact of work environments such as hospitals on nurses, physicians, and other employee's health… around the world that most of them have been carried out quantitatively, and experimentally, but working conditions in work environments such as hospitals in Iran, especially for women, are different according to the above. Since qualitative studies provide a better understanding of phenomena and can explain human experiences, interpretations, and perceptions in cultural and social contexts,[2021] there is a need for qualitative research in this field. Therefore, this study is based on the qualitative content analysis approach with the aim of exploring the characteristics of a psychologically supportive environment in a workplace from the perspective of female hospital staff.

Materials and Methods

Study design and setting

This article was part of a larger study conducted through qualitative content analysis from July 2019 to March 2019.

The interviewer of this study was a Ph.D. student in health education and health promotion who had experience participating in qualitative research workshops and was familiar with the subject. Before the interview, the interviewer met the participants and introduced herself, and held an appointment with them to conduct the interview. She also played a neutral role and behaved friendly and tried not to interfere the interview with her own opinion.

Study participants and sampling

Participants in this study consisted of women working in one of the hospitals in Tehran who were selected in a purposeful design with maximum diversity in terms of age, work experience, place of work in different departments of the hospital, and their position in the department such as nurses, auxiliary nurses, supervisors, officials, and doctors were working in the hospital.

Data collection tool and technique

The data collection tool in this study was a semi-structured interview with the interviews conducted in person and face to face. A purposive sampling technique was used. In this study, 26 female hospital staff, supervisors … in Tehran between the ages of 24 and 40 years and older participated who had at least 2 years of experience in the hospital. Furthermore, to increase the validity of the data, it was tried to use the maximum population diversity. Three participants did not attend the interview due to their busy schedules. Data were collected at the workplace of participants who worked in the hospital usually in the nurses’ restroom without the presence of anyone other than the interviewer and interviewee.

Interviews were started with the main question as “What can be the mental environment that supports women's health in the workplace such as a hospital?” and then continued with some questions such as please explain more to give depth to the questions. For more information on the subject, other exploratory questions were asked according to the answers of the samples. The interview guide developed for this study is provided in Table 1.

Table 1

Interview guide

Interview guide questions
1	Core question	Probe question	Field notes
2	What do you think is the mental environment that supports women’s health in workplaces such as hospitals?
3	What are the factors that can be effective in creating a mental environment that supports women’s health in the workplace?	Explain more about each aspect?
4	What are the different aspects of a workplace that supports women’s mental health? check in all directions	Explain more about this

If we needed additional information, would we be allowed to contact you again?

None of the interviews required a re-interview. Field notes during the interview and observation were also used in data collection and analysis. The duration of the interview was within 20–30 min due to the busy working of women operating in the hospital. The interviews were returned to the participant for commentary, and in some interviews, a summary of the interviewee's statements was read as a title to the interviewee to clarify the veracity of their statements. Data collection continued until data saturation and no new data was available.

In this study, the conventional content analysis approach was used. Content analysis is a qualitative research method used to analyze the data, and it is a systematic classification and coding technique aimed at a better understanding of the phenomenon under a study.[22] In the present study, the data analysis process was performed according to the steps proposed by Graneheim and Lundman.[23] Furthermore in this study, data collection and analysis were performed simultaneously. Audio recordings were used for the interview and transcribed verbatim into a Word file after the interview. Besides, the entire material was reviewed several times to gain a correct understanding. At the data preparation stage, to get acquainted with the data, the entire text was read in full and the researchers immersed themselves in understanding the contents of the interviews. According to the content and text, the sentences and paragraphs of the interviewees were considered as the smallest units of analysis and considered as the initial codes. The codes were then sorted into subgroups and categories by comparing their similarities and differences. In the end, the main category in which the subgroups were placed reflected the content and hidden concepts in the text.

Goba and Lincoln criteria were considered to ensure the validity and robustness of the research.[24] Credibility was gained by reviewing manuscripts by participants and the researcher's long-term involvement with the research field plus participants. By maintaining the neutrality of the researchers as well as reviewing the codes and classes extracted by the two members of the research team and reaching an agreement, verifiability was achieved. In addition to semi-structured in-depth interviews to reinforce the data, sub-methods such as observing and documenting field notes during the interview were used. Reliability or consistency of findings was provided by typing and analyzing interviews as soon as possible, using the opinions of colleagues in qualitative research and experts in the field of health promotion in the workplace, and reviewing the entire data. The transfer was also made possible by providing many direct quotes and rich data descriptions.

Ethical consideration

To comply with ethical considerations, participants were informed about the purpose and necessity of the research before the interview and participated in the research with informed consent. Further, to respect the rights of the participants, due to their busy schedule at the hospital, they were arranged for an interview and an appointment was arranged with them. Furthermore, the interviewees were asked to allow audio recording, with the purpose of the research and data collecting method explained to them before the interviews. To ensure the confidentiality of the information and to get them involved in the study before the interview, informed consent was obtained from the participants. Participants were then assured that the interview would remain confidential, with the research team and in a safe place, and that they would have the right to refuse to continue the research if they did not wish to continue.

Results

The demographic information of the study participants is reported in Table 2. The study participants were 26 women working in one of the hospitals in Tehran. Most of the women were married (69.23%), age 25–30 (19.23%), 30–40 (42.3%), above 40 (36.46%), and most of the women had work experience 10–15 years (30.76%).

Table 2

Categories, Sub-Categories, and codes

Categories	Sub-Categories	Codes
Noticing occupational stressors	Noticing the causes of burnout	Work stress in the hospital environment
		The exhausting nature of working in medical centers
		Facing the pain of patients
		Patient-centeredness
		The effects of the night shift on physical and mental health
		Workplace and homework pressure
		Physical health problems due to the high working pressure
		Existence of multiple acute situations in hospital conditions
		Stress associated with physical work
Women’s occupational stress management	Women’s psychological empowerment	Creating social support for the spouses’ network
		Get the support of spouses
		Couples’ relationship training
		Forming self-help parenting groups
		Empowerment of women in parenting
		Holding training courses related to mental health
		Teaching effective communication with the patient
		Training to communicate effectively with colleagues
		Mental health counseling
	Providing programs for women’s mental improvement	Prepare group psychology sessions for women
		Plan trips to reduce women’s stress
		Development of sports and physical activity for women
		Noticing extracurricular programs to reduce women’s work stress
		Noticing important occasions
		Provide recreational camps to reduce women’s stress
Providing psychological-occupational satisfaction of women	Creating satisfaction and psychological security	How to deal with women’s career mistakes
		Creating a sense of psychological security in the workplace
		Establishing effective communication between colleagues
		Supporting working women against client violence
		Seeing the positive work of women
		Paying attention to the economic needs of women
		Fair management of organizational promotion
		Managers’ mutual understanding of the situation of working women
	Improving the utility of the hospital working environment	Existence of workplace peace
		Spiritual health in the workplace
		Workplace beautification
		Workplace vitality
		Create a dynamic workplace
	Providing facilities and conveniences for supporting women	Providing facilities and equipment for mental health
		Reliable transportation service
		The effect of distance from home to work on women’s perceived stress
	Motivate work	Provide spiritual incentives to women
		Consider financial points for women
		Pay attention to individual interests in being in hospital wards
Balancing the work and life of women	Supporting women in special family situations	Work time flexibility for pregnant women
		Pay attention to the problems of keeping the child in the night shift
		Facilitate the care of children and infants under one year
		Provide alternative force during emergencies
		Night shift management in women with family problems
		Paying attention to family problems in the work arrangement of women
		Supporting mothers with children with special illnesses
	Provide work-life balance interventions	Provide information support to moderate work-life interactions
		Empowering women in role management
		Managing the impact of environmental job stress on family life
		Interactive support for managers
		Workplace stress management training
		Collaborative work arrangement

The psychological environment supporting women's health in the workplace was charted as the central variable. In the process of data analysis, 58 concepts with the same characteristics were converted into 10 subcategories and then into four main categories based on common features at a more abstract level that are reported in Table 2.

Mental environment supporting women's health in the workplace

The mental environment that supports women's health in many workplaces can have a significant impact on the organization in addition to the individual. In this study, the psychological environment supporting women's health in the workplace included the following subcategories:

Noticing occupational stressors

Working in the hospital environment puts a lot of stress on employees; whether they are in the treatment department or the hospital administration, these stressors can affect all of these people. Burnout, hospital work tension, the nature of work in medical centers, exposure to patients and companions, workplace and home environment work burdens, lack of facilities, physical health problems due to high work pressure, existence of multiple acute situations in the hospital, pressure associated with physical work, sleep disorders, and physical and mental problems caused by night work are some of the factors that the participants in this study named as stressors in the workplace. Evaluation and regulation of these factors can be important and influential on creating a mental environment that supports women's health in the workplace.

The hospital is full of anxiety and stress; in any of its areas, it does not matter, each side has its own problems, each has its own stress and anxiety...(Participant No. 18

The administrative staff of the hospital is more stressed than other organs. We are far more in number than even our own administrative staff. This causes us not to have mental health. We have a lot of stress...(Participant No. 14)

Fatigue due to night work was also one of the issues raised by the hospital staff, especially the staff of the treatment department:

You are always tired and nothing can replace a good night's sleep at all ... you are always confused and you are always in a state of confusion ... and this affects a person's mood and mental state. (Participant No. 14)

The nature of work in medical centers is that the staff of these centers deal with pain, illness, and sufferings of people and this can have a large impact on their mental health:

Anyway, here, mentally, we are dealing with people's pain and suffering, maybe a high percentage of us suffer from depression, from mild to severe, and other psychological problems that the system can care for...(Participant No. 21)

Meanwhile, one of the issues mentioned by the working women of this hospital was the lack of facilities in providing services, which will be accompanied by the dissatisfaction of the patient and his companions, and this can put them in tension:

In the emergency room, the patient's companion starts making noise, swearing, well why did this happen? Because there were not enough beds and this puts us in tension...(Participant No. 15)

Women's occupational stress management

Managing women's perceived stress in the workplace is a key issue an organization and work environment like a hospital can do to form a supportive psychological environment for working women. Stress can cause many problems for employees, especially women working in hospitals, and if the organization does not seek to mitigate these pressures and problems, it can affect the organization in addition to affecting staff, especially women. Women's psychological and social empowerment was very important for women participating in this study and effective in reducing workplace stress, in their opinion. Creating social support for the spouse network, teaching role management to couples, holding women's mental health training courses, and having women's mental health counseling are some of the thing's women working in the hospital mentioned that can be effective in creating a supportive mental environment for them and can help reduce stress at work, especially in the workplace with a lot of stress and tension, such as a hospital. As some employees mentioned:

I think there should be an education that really teaches women what behaviors women should have at home so that at least we do not face challenges and problems at home, and this helps them a lot... (Participant No. 9)

Dealing with the patient and how to behave toward a sick person and his companion, all of these require training ......(Participant No. 5)

Indeed, in working environments, in addition to those physical facilities, there must also be mental facilities and counseling, so that you have someone in the hospital you can easily talk to. A manager, a doctor, or counselor can solve many things ...(Participant No. 7)

We have very little or no social interaction education; especially we do not have a panel discussion or a conference at all, but in an employee-based work environment, there more of such education and they bring a psychologist for them to speak. But not in our environments when there is a serious need for that ...(Participant No. 17)

Providing programs for women's mental empowerment

Stress and burden due to work-life interference and functional role tensions in work environments such as hospitals, which are more stressful than other work environments, sometimes require the organization to provide some programs. According to the participants in the study, preparing programs, though simple and low-cost, can help women in the workplace to have a better mental state to continue the work process. The development of sports and physical activity in the hospital working environment has been one of the important issues that female staff mentioned as a very important factor that can affect both their physical, mental, and social health positively and can relieve the stress of heavy daily work. Simple programs such as family trips or day camps with colleagues, joyful extracurricular activities for different occasions, development of sports and physical activity, special programs and simple gifts for important occasions such as birthday, nurse's day, and employee day are very simple elements that can reduce the psychological pressure on women by having a happy day away from any stress, as some participants in the study stated:

One of my friends is abroad now. She says that every month some of our salaries must be saved and at the end of every 6 months we have to go on a forced trip; it would be better if our organization has such programs too... (Participant No. 2)

The working hours that we have here are very long, it will be great if they set a place here where, for example, women can go for an hour to exercise and get energized before going home,…

a small club to exercise to protect the women from depression.

Another thing is that they can organize a joyful program and gather staff in the amphitheater and away from all the limitations, occasionally, for example, twice a year ... I think this program can have a great effect on the morale of the staff ...(Participant No. 6)

Due to the administrative atmosphere of the hospital, it can be mentioned that the exemplary staff should be appreciated and given a small gift. For example, on the employee's day, one or more employees from each department can be selected as exemplary employees... (Participant No. 6)

They must consider a situation, a recreational camp, anything that distracts us from the stress of this environment ...(Participant No. 16)

Providing psychological-occupational satisfaction of women

Job satisfaction and psychological safety is another subcategory of the psychological environment that supports women's health in the workplace. In this study, concepts such as how to deal with job mistakes, creating a sense of psychological security in the workplace, effective communication between colleagues, supporting working women against client violence, the manager's mutual understanding of the situation of working women, helping the positive work of women to be observed, fair management of organizational promotion, and attention to women's financial needs have been taken to be effective in establishing a psychological environment supporting women.

According to the participants in this study, the peace of managers and officials can create a calm and stress-free environment, an environment in which mistakes and errors made lead to the provision of a foundation for education and learning, and thus you can have a sense of psychological security for women.

When the atmosphere is peaceful, when they are calm, even if I make a mistake, I will not get too anxious about what happens then and ... I mean I will be anxious, but at least I will not be anxious about how to deal with them. I will know that we just go there and talk and raise the problem and try to solve it together.(Participant No. 3)

When problems arise, we should not exaggerate them so much that the staff gets stressed, we should try to guide the other person more, instead of humiliating her, so that she does not have stress and can work without stress next time.(Participant No. 2)

Many participants also see the workplace as a supportive environment that recognizes women's problems, such as the multiplicity of their roles in life, and pays attention to the positive things they do. Issues such as women's financial security are also considered effective in creating a sense of security and job satisfaction:

there would be great if principals could understand what problems women have, what it means to have an infant, what it means to be a mother, what it means when you go to your house you will be a mother then, it does not matter what a hard shift she went through and what happened in that shift ...(Participant No. 1)

But as a hospital or university staff member, I have nothing of myself, I am thinking that if one day my husband does not want me, I have nothing of myself. The government did not leave anything for me and did not satisfy me ...(Participant No. 12)

Many participants also considered factors such as system support and management in the event of patient and companion violence as the reason for their sense of security and believe that they are effective in creating a sense of security and job satisfaction. Participants in these cases said:

When I see the patient's, companion insults me and I cannot say anything to him, I would like I have a right too. When a problem arises, the administration, in any case, gives all the rights to the patient... (Participant No. 14)

Improving the utility of the hospital working environment

The desirability of the workplace is another category that can be important with a significant impact on the mental atmosphere that supports women's health. Factors such as peace, freshness, beautification, as well as the dynamism of the workplace, can have a great impact on creating a workplace where women can have the required efficiency and productivity. The hospital environment is an environment that can affect women in many ways. Facing illness and pain of people, heavy workload, long working hours, and multiple roles and different pressures and stresses that may exist for a woman in the workplace can impact the women's health in many ways. Thus, having a desirable, fresh, beautiful, and dynamic workplace can affect employees, especially female employees, and reduce the psychological stress caused by hard work. As the participants in this study stated:

The first thing is having peace in the workplace. When the work atmosphere is calm, your mental health will be fulfilled and you will be able to think and decide better and work better with your colleagues and make a better relationship with them accordingly ...(Participant No. 5)

There are many complex issues here to help psychologically. A lot has to be planned; There should be a lot of special planning, for example, to make the work environment fresh, or to make small changes in our resting room, to buy a flower every once in a while, for there, where a small change in that environment can change their mood.(Participant No. 7)

Providing facilities and conveniences for supporting women

Providing equipment and facilities such as work-related equipment and facilities that will bring welfare to female employees, especially in workplaces such as hospitals, in addition to helping the organization for doing things properly and speeding up service delivery, can also have a significant impact on women's mental health and well-being. According to many study participants, when equipment and work facilities such as hospital beds, treatment equipment, and equipment related to the safety of patients and staff are well provided in the hospital, it can affect both physical and mental health as well as the stress of the staff and nurses, as participants said:

But when a hospital is sufficient in terms of human resources and facilities, in another word, it has no deficiency, it certainly affects us positively. When we want even just a pair of gloves, if we are going to face a lack of that, we get stress because we realize that we don’t have any and we should look for it a lot ... it preoccupies our minds mentally and threatens us physically ...(Participant No. 3)

“A lot of these issues happen; the patient's companion starts shouting and swearing, because there were not enough beds in the emergency room; if there were enough beds, the patients who needed a CCU last night would be admitted, then there would be enough beds and facilities to admit the other outpatients, and that would not stress us out.”... (Participant No. 15)

It is very important to provide adequate equipment, especially for nurses doing clinical care by patients’ beds, and also providing services, as well as facilities such as babysitting, safe transportation service, and a standard rest area that caters for their well-being. One of the participants in this study said:

When a mother is sure that her child is in a place where they can care for her/him physically, mentally, and emotionally and is assured of her child, she will certainly not neglect her work and will do her job in relaxed way and perfectly ....(Participant No. 13)

On the other hand, the distance that women drive from home to work can also be effective in creating tension and stress in them. According to women working in the hospital, the distance from home to work may not have much effect for men who have fewer roles in housework. However, for working women who have multiple responsibilities at home, in the community, and at work, it can be an important factor and the resulting tension will cause problems for them. Thus, the organization and managers of the hospital should pay attention to this important matter and be able to manage it well:

Unfortunately, in my opinion, it is very difficult for some people to be so far away from the workplace, especially for women. We do not have transportation services for all shifts; We only have such a service in the morning, while we do not have an evening night service. For some women whose house is very far from the hospital, that is really hard and they endure a lot of stress ...(Participant No. 7)

Balancing the work and life of women

Work-life balance is one of the most important factors that can have a significant impact on the mental and social health of employees, especially female employees and nurses who work in hospital workplaces, while also challenging the organization to create an environment that supports women's health ... Many women working in hospital circumstances have difficulty balancing their work and life due to heavy workloads, long shifts in a row, having night shifts, and so on.

The adaptability of working hours for pregnant women, maternity leave, facilitating child care in night shifts, facilitating childcare and infants under 1 year old, alternative labor during emergencies, night shift management for women with family problems, support for mothers with special children, information support for modulation of work-life interaction, empowerment of women in role management, management of the impact of environmental job stress on family life, interactive support from managers, management of participatory work arrangement and instrumental support from the organization in specific family situations were some of the issues expressed by the participants in this study.

Many of these women, in addition to the roles they play in their community and family as spouses, mothers, children, etc., also play important and vital roles in workplaces such as hospitals. If they cannot manage these multiple roles, conflict of roles happens which can affect their psychosocial health too. Pregnant women, women with children under 1 year of age, and infants or children with special conditions need hospital support to manage this multiplicity of roles.

On the other hand, some female nurses and staff at the hospital also stated that night shifts may not be accepted by some spouses which cause many familial problems. Thus, many factors can be effective in building this balance between work and life:

women who work here are married and their spouses don’t work at the hospital necessarily and they work in other fields. It is difficult for them to accept that their spouse has a night job or a morning and evening holiday shift, which leads to some struggling ... they have to learn to manage it, but in places where the marital situation is very deteriorating, the organization must find a solution and help them ....(Participant No. 18)

One of the concerns expressed by working women participating in the study was child-keeping stress. Child-care centers, especially for infants, can be a major concern for working mothers, and the standards of the childcare place as well as its closeness to the mother's workplace can reassure mothers that they can pay attention to the roles assigned to them in the workplace without worrying about the childcare.

For example, those who have children worry that when they are at work their child stays with whom and how much he is bothered, the hospital can provide this facility and provide more welfare equipment for staff in the workplace.

In general, if there is a woman who has a night job, she cannot leave her child anywhere, especially if her own family lives in other cities and there is no one to take care of her child, a night nursery can help her ...(Participant No. 7)

What the participants in this study stated is that when the system and the staff interact properly, they can work together in different situations. When the female staff work well with their colleagues in the ward as well as with the head nurse in difficult hospital conditions and interact well with their colleagues, while the system along with the hospital management system has appropriate cooperation and empathy with working women when there are family problems and out-of-work issues, a work atmosphere will be formed where both sides are satisfied with and in fact, it will create constructive interaction between them. This environment could finally support women working in hospitals. Thus, the cooperation of the ward managers and head nurses in women's work arrangements in workplaces such as hospitals and participatory work arrangements can be of great help in balancing work and life for women:

As a head nurse, if the staff does not really understand each other, when a problem arises for themselves, their family, or their children, it can be said that co-workers certainly do not feel safe.(Participant No. 18)

One of the most important factors that help working women in work-life balance is empowering them in areas such as managing the roles they play in their family, community, and workplace, as well as managing the impact of job stress on family life plus the impact of the two on each other. The organization can plan to train and empower them and strengthen women in the hospital for that.

A woman has to be able to manage roles, some women who you interview, do not even know how to manage roles nor do they know the contradictions of their roles, nor do they have self-knowledge ...(Participant No. 18)

These are educational things and because we did not learn, we have a lot of problems, because we do not have a balance between work and life and everything can be done, especially in the hospital... (Participant No. 9)

Discussion and Conclusion

Working in hospital workplaces and medical centers puts a lot of stress and tension on staff, especially women, including hospital environment tensions, facing with patients’ pains, night work, patient-centeredness, and the utter attention of hospital managers to patients’ satisfaction, long hours, and the presence of multiple acute conditions in the hospital. All these can have a significant impact on creating a supportive mental environment for female employees, as expressed by the participants in this study. Numerous studies have shown that prolonged exposure to job-related stress can lead to burnout, which is defined as a psychological syndrome that may occur if employees are exposed to a stressful work environment with high job demand and limited resources, which endanger not only their health but also yields higher medical fallacies and poor quality of optimal care.[25] Persistent job stress affects not only the quality of services but also the health of health-care providers.[26] Further, studies have shown that job stress is associated with burnout and if the stress of the hospital environment is reduced, it can also mitigate burnout.[27]

Participants in this study considered factors such as lack of facilities and equipment including child-care centers, transportation service, and the necessary equipment to provide quality services to patients as important factors which if provided by the organization are very important and influential, especially for employed women. Studies have also shown that factors such as equipment and facilities for providing services can affect the workload and stress on hospital staff, especially medical staff, and female nurses. Factors such as lack of proper supplies, lack of nurses, and poor management performance will be influential factors and if superior management fulfills their responsibilities in terms of equipment required to provide quality care, it will greatly reduce the stress on employees.[28]

Furthermore, studies have found a significant relationship between emotional burnout and physical environmental conditions as well as professional facilities of the department. This means as the desirability of the ward decreases in terms of physical and professional facilities, the rate of burnout increases. When equipment and facilities are not readily available, nurses suffer from down mood and anxiety as well as long-term burnout.[29] Thus, the organization can have a significant impact on creating a psychological environment that supports women by considering the provision of appropriate facilities and equipment.

In this study, one of the factors that had a great impact on nurses, especially female nurses were considering the effects and harms of night work on health, especially women. Paying attention to this problem and managing its effects can be effective in making a supportive environment. All nurses and hospital staff must work shifts, and night work is a characteristic of hospital work. Studies have also shown that stress from work shifts can impair health and lead to heart disease or gastrointestinal disorders. Many of them work in the evening or weekend shifts at work and sleep during the day, so they often lose their social or familial activities.[30] Meanwhile, some studies have reported that working in shift change is associated with decreased job satisfaction and increased job stress. Evidence shows that night shift work is associated with increased fatigue, changes in sleep patterns, and accelerated burnout. The relationship between the type of work unit and nurses’ job satisfaction as well as job stress has also been confirmed in some previous studies.[31]

Managing work-related stress and tension was one of the factors that the study participants cited as a very influential factor in creating a supportive psychological environment for women in the hospital. Nursing and working in medical centers are some of the most harmful occupations. Dealing with a client who is sick and has lost his or her physical health and subsequently his or her morale is difficult and exhausting. Observing the patient's pain, patients suffering from an incurable disease, children with chronic illness, death of the patient, and weeping of their companions all cause anxiety and worry in medical staff and subject them to various occupational injuries, including reduced mental health and burnout.[32] Other factors such as role overload, role incertitude, work shift, physical factors of the work environment, lack of facilities[3334] managerial style of administrators,[35] and relationships between colleagues are among the important job-associated stressors in nurses’ community which can affect their job dissatisfaction.[203637] Studies in Iran have shown that the average score of job stress in female nurses was significantly higher than that of men. This difference may be because in Western culture, society, families and the workplace have similar expectations of men and women. According to studies, stress is one of the main problems of nurses that has a great impact on their professional performance plus personal life and causes a conflict between work and life. The effects of job stress can disrupt people's relationships, especially spouses’ relationships, and their suffering and distress can in turn be transferred to children, damaging their quality of life.[32] On the other hand, although it is impossible to eliminate stress completely, people can learn to manage it.[21] Studies have shown that management strategies are used to empower and support nurses so that they can cope with and adapt to stressful situations effectively, i.e., can help them control and reduce stress.[3839] Furthermore, group therapy studies have revealed that holding training sessions helped participants to identify situations that are stressful in the workplace and set the ground for dealing with them.[40]

Participants in this study suggested other ways to reduce and manage the stress that can be very effective in forming a mental environment, supporting women's health, and reducing the stress caused by an immense workload and job stress in medical settings. The examples include providing trips with family and co-workers, developing a culture of physical activity in the hospital, preparing happy extracurricular activities, preparing programs for important occasions, preparing camps with family and co-workers. Various studies have shown that factors such as physical activity as well as regular and extracurricular exercise can be effective in reducing anxiety, stress, and tensions in the workplace.[41] Many organizations have interventions to improve mental health such as meditation, relaxation, and deep breathing. Regular physical activity can also be an effective intervention. Studies have shown that exercise and physical activity in the workplace can be somewhat effective in controlling and managing these stresses.[42] Studies have also indicated that physical activity can improve social cohesion, social acceptance, social participation, and overall psychosocial health score.[4344]

Planning job satisfaction and psychological security in the workplace was another issue that the participants in this study mentioned as one of the important factors in creating a supportive mental environment. One aspect of job satisfaction is its relationship with employees’ mental health. In addition to providing financial resources, employment has a great impact on satisfying some basic human needs, such as a sense of self-worth. Nevertheless, if the organization does not pay enough attention, it can be a source of stress and hurt the mental as well as physical health of employees. The stress that comes with being dissatisfied with work can predispose a person to a variety of illnesses. Furthermore, studies have reported that employees are more satisfied, more productive, more creative, and more committed, and finally, care for the patient with higher quality care more about the quality of work and are generally productive.[45]

One of the factors that the participants in this study declared as an important factor for creating an environment with a sense of mental security is job mistakes and how to deal with them which can have a significant impact on having a constructive and stress-free environment for women. Evidence shows that mistakes lead to feelings of guilt, humiliation, embarrassment, self-blame, frustration, and loss of confidence in nurses.[4647] Although supporting and creating a constructive environment in dealing with mistakes can solve this problem, unfortunately, research shows that inappropriate feedback, inadequate response of managers and the organization to the wrongdoers, managers’ concentration on wrongdoer staff and nurses while neglecting other related factors, lack of support from managers and the existence of a culture of punishment and blame not only contribute to the failure of reporting the error but can also affect the mental health as well as on establishing a supportive and constructive environment for nurses.[484950]

Other issues raised by the participants in this study included how the system supports and manages nurses, especially female nurses while being exposed to violence. Violence often occurs in workplaces such as hospitals, where employees interact with different people, both inside and outside the system, as patients and their companions.[51] What is important and can create a mentally healthy environment for staff, especially female nurses, is supporting them against this type of violence. Nurses, especially female nurses, need the personal support and emotional help of managers after any violent incident;[52] however, many managers may not fully understand the impact of such events as they are far away from clinical settings.[53] This lack of personal emotional support causes nurses to feel uncomfortable and insecure.[53]

Issues such as fair management of organizational promotion away from any gender discrimination or discrimination between employees can also be very effective in creating a sense of psychological security for women. Yet still, the majority of employment and job positions are less attainable for women. In this regard, higher job and organizational positions that require expertise and education are given to women only if they do not seek and demand those positions on an equal footing with men, which can damage the creation of a justice-oriented environment that supports women's rights.[54]

Achieving work-life balance is an issue that can be achieved with effective management strategies.[14] Studies have reported that high work-family conflict can have negative consequences such as job and life dissatisfaction, significant anxiety, stress, physical symptoms, depression, burnout, and marital dissatisfaction, as well as reduced accuracy and quality of service delivery at work.[55] On the other hand, studies have shown that administrative and organizational support, family support, work experience, and being a woman are the predictors of high-level work conflict in the family, while organizational and familial support, gaining experience during years of work, education, and empowerment can be effective in moderating this issue.[56] As the study participants also stated, one of the things that can be effective in balancing work and life for women is the support for female employees that the workplace and its managers can provide in case of family problems such as having infants or sick children or when family and marital problems occur. This was stated in a study as one of the important factors in the balance of work and life of women.[57] On the other hand, studies have shown that training related to nurses’ quality of work-life and resilience plus stress management and burnout skills can be effective in quality of work time and work-life balance.[58]

Limitations and recommendation

Since the study participants were hospital staff, interviewing them was very difficult due to their busy schedules and required a lot of coordination. This was solved through coordinating with the managers and adjusting the interview time with the participants beforehand.

This study revealed that supportive psychical environments for women in workplaces such as hospitals are influenced by various factors such as recognizing and managing women's job stress, providing the equipment and facilities required by women, balancing the work and life of working women, and creating a sense mental and occupational security. Furthermore, creating supportive work environments for women, especially women in environments such as hospitals, which incurs a lot of work burden and workload to them, can be an important policy for organizations and hospital workplaces. To create a suitable and supportive work environment for women, hospital managers and administrators should organize social evidence-based interventions and attract the participation of working women so that they can actively participate in the affairs of the organization and achieve this important goal together.

Financial support and sponsorship

This research was supported by grant No 98-1-2-14479 from the Iran university of medical sciences.

Conflicts of interest

There are no conflicts of interest.