Sustainable Management, Instable Legislation Regarding Wages, and Employee Satisfaction/Motivation in Two Romanian Hospitals

Abstract

The aim of our study is to evaluate the employees’ level of satisfaction/motivation in two Romanian public hospitals in the context of numerous changes of the legislation concerning the level of payment of the employees working in the healthcare system, and to reveal the characteristics of a proper, sustainable management in this type of public healthcare unit. During 2015–2018, 4945 questionnaires were distributed to the staff of both hospitals, processed, and analyzed. In the Clinical County Emergency Hospital of Oradea, the analysis of the questionnaires showed a decrease in motivation (from 94.63% in 2017 to 79.14% in 2018). In the Timisoara County Clinical Emergency Hospital, for all the categories tested, there was a slight increase of the motivation. All the professional categories showed a degree of satisfaction with ascending evolution. Motivations of a different kind than the financial one, reinforced by the hospital’s management in recent years, have led to a general degree of employee satisfaction, 96.95% of them being satisfied that they work in the hospital. In the current unstable legislative context, financial motivation cannot be influenced by the management of public hospitals; therefore, the most appropriate measures that are needed must be geared towards increasing non-financial motivation.

1. Introduction

Durable management represents the junction of business and sustainability. It can be defined as the conceptualization, accomplishment, and assessment of both socioeconomic and environmental durability—connected decisions and activities. It refers to the application of managing the impact of a company on three basic lines—planet, people, and profit—so that all can progress in the future [1]. Sustainable business management goals are being pursued by a growing number of organizations in many industries including healthcare. There are various perspectives from which durable management and its integration can be evaluated. These comprise tactical management, organizational evolution and transformation, replacement of agents and managers, organizational studying, durable organization, stakeholder commitment, durable business patterns, and business conditions for durability [2]. Both the environment from within the company and the external environment have an impact on the selection of persons or organizational units to be in charge of the durability management and the demand to be carefully noticed [2,3].

Among the first priorities concerning the management organization for durable development for the medium and long term there should be employee satisfaction and motivation [4]. Several factors can influence employee satisfaction: wage, the specifics of the job, leadership, working conditions, and working groups [5].

In order to enhance the quality of the healthcare service, to achieve superior health results, the evaluation of satisfaction is extensively used. Numerous studies have shown that healthcare personnel with great satisfaction ensure medical services of superior quality, determining improved healthcare outcomes and enhanced satisfaction of the patient [6,7,8]. Nowadays, there are numerous ways to evaluate the medical personnel satisfaction around the world [9]. Every instrument has its own traits, application domain, is aimed at a specific population, and is not totally constant. The instruments for assessing work satisfaction in medical personnel comprise universal scales (like the ones applied for healthcare service personnel, all service personnel, etc.) and particular scales (like the ones applied for hospital workers as doctors and nurses, dentists, home care nurses, etc.). The evaluation of the subjects may be performed on extensive populations for these parameters or may be a specific professional classification [10,11].

The results found in the literature data associate the satisfaction of the medical personnel with the following factors: the job itself, hospital administration, the environment in which one performs his/her job, job bonuses, working domain, and ambience [10]. Some studies have highlighted an uncommonly major impact on job motivation/satisfaction of the personnel, the level of motivation having an effect on the yield, and therefore on the efficiency, of the organizations [5]. According to some authors, the efficiency represents a part of the individual stimulation, organizing tactics, and patterns, and the ability to resist to change is a pragmatic part connected to the motivation in the institution [12]. In terms of people’s workload, it is significantly influenced by salary, which is one of the motivation tools both theoretically and practically from the economic point of view. For motivating the human resources, the salary has an extremely important role [4]. Recently in Romania there has been an increased concern for effective salary policy inside the institutions. A complex activity is represented by the progress of the salary policy, which requires reflection concerning all features related mainly to the duties and basic functions, wages and their correlations with the most difficult social and economic factors that may vary, and often their divergent implications on all the interests of the enterprises [4].

Romania’s accession to the European Union in 2007 led to the increased emigration of Romanians working in the medical sector [13,14,15]. The main causes of medical staff emigration were income differences, career development opportunities, and the adoption of austerity measures imposed by the Romanian Government in 2010: a 25% reduction in salaries for budgetary employees (also applied to medical staff) and blocking of posts in the sanitary system. Thus, in the country report of the European Commission of 2016 [16], staff shortages in the healthcare system are highlighted. The emigration of qualified medical staff (doctors and nurses) from the country is considered expensive for Romania due to the loss of investment in education (which involves high financial costs in training) and the distorted labor market [17]. In order to reduce the emigration of medical staff and to increase the return of doctors in the country, the Multi-Annual Plan for the Development of Human Health Resources was developed [18,19], and consistent salary increases were applied for doctors and nurses as of 1 March 2018 [20].

Law no. 153/2017 regarding the remuneration of staff paid from public funds has had a major impact on the medical staff employed in Romanian medical institutions. The unitary approach of the wage law to each field of activity has led to some salary adjustments. Salaries have been adjusted, by addition or subtraction, to fit into the pay scale set out in the normative act [20]. The basic salaries of the staff working as physicians and nurses in public health establishments were increased to the level of the basic salary for 2022. For the other categories of staff, wage increases are to be gradually made until 2022 when the will reach the level established in the pay scale. In addition, Law no. 153/2017 provides for a maximum level of the allowances granted in the health and social assistance system, at 30% of the amount of the basic salaries at the level of the main credit officers. For budgeting, most medical institutions (especially hospitals) were forced to apply the minimum allowances for the specific conditions associated with each job, which meant that for auxiliary and non-medical staff (nurses, caregivers, grooms, workers, administrative staff), the wage growth is insignificant.

In the healthcare system, human resources (healthcare professionals) are the most valuable, and organizations that practice human resources management based on skills (continuous growth of knowledge and skills), motivation, and opportunities (to assume decision and responsibility) are more efficient. The rational use of human resources in health also involves reducing differences and barriers between types of staff [21], as well as remunerating and delivering benefits in accordance with performance. It should not be forgotten that the loyalty of professionals with occupations specific to the healthcare system (doctors, nurses, etc.) goes first and foremost to the patient and their profession and only later to the employer. A motivated and adequately prepared workforce is a basic element for improving the performance of the health system [22,23]. The main negative factors influencing the medical staff in the Romanian medical organizations, mainly in the public hospitals are staff shortages (blocking of posts, staffing norms that are inadequate to current needs, migration of doctors and nurses); inadequate pay (low wages compared to the countries of the European Union, fixed status—on the same job, the same salary—without taking into account individual competence and performance); infrastructure; obsolete medical equipment; inefficient computer system; and poor communication. Over the last few years, a series of measures have been implemented aimed at counteracting the listed factors, but with no notable results.

The legislative changes regarding the salaries of the Romanian medical staff were aimed at aligning wages (doctors and nurses) close to the wage levels in the European Union. The aim was to stimulate the medical staff by increasing their motivation in order to improve the quality of the provided medical services and the performance of the organization. Along with the wage increases, most public hospitals in Romania faced a state of tension among medical staff generated by the application of the Wage Law (major discrepancies between the salaries of doctors and nurses over the rest of the staff employed, but also the decrease to minimum of the allowances for employment-specific conditions, due to the legal provisions to grant a maximum level of allowances corresponding to 30% of the basic salaries at the level of the main credit officers). The main factors of influence mainly focused on inter-social relationships such as the quality of communication with the medical team, loading with tasks and activities for some categories of staff, personality and behavior at the workplace, and granting and receiving support.

The Clinical County Emergency Hospital of Oradea (CCEHO) has undergone an unprecedented process of development in the last years, including changes in the structure corresponding to the needs of the population (introduction of new medical services), rehabilitation of existing spaces (bringing them to the standards and norms in force), unique modernization and medical endowment, access to new health programs, and increase in number of employees (selected by competition) [24]. Effective hospital management has allowed the payment of training courses, additional days of study leave, food and holiday allowance to the hired staff, implementation of measures dedicated to ease the work of the employees, as well as increasing their comfort in the workplace. All these changes [25,26,27] were aimed at providing quality medical services and good professional performance in correlation with increasing professional satisfaction [28,29,30]. Employee satisfaction is assessed periodically (twice a year, February–March, September–October).

Timisoara County Clinical Emergency Hospital (TCCEH) provides medical services at high standards regarding the complexity and quality of medical act and hotel conditions for the entire Banat area, 71.72% of patients coming from Timis County. The main objective of its activity is to increase the capacity to provide complex medical services centered on the patient, improving his/her health and satisfaction in the conditions of quality and economic efficiency existing in Romania.

The salary increases in 2018 should have had a positive effect on the motivation of the staff, especially doctors and nurses, but the latest analyses showed, for some categories of staff from different structures, a decrease in the degree of motivation [31].

This study aims to evaluate the level of satisfaction and motivation of the employees of both mentioned hospitals, in the context of the salary increases, but also of the instability of the legislation in force regarding the remuneration of the personnel; additionally, it describes some conditions/characteristics that ensure an efficient and sustainable management in such a framework. It has been assumed that the individual expectations are related to motivation, and the rewards obtained from work are related to work satisfaction. The analysis highlighted the extent to which the employee is satisfied at the workplace, determining hospital management to develop appropriate measures. In order to have a full image on the aspects to be analyzed (satisfaction, motivation, salary level), we considered that a comparative study of two hospitals (with the same profile, both university clinics, from different but close counties of Romania) has to be conducted.

2. Materials and Methods

2.1. Methodology

The study was conducted in two Romanian hospitals, namely CCEHO and TCECH, by analyzing the satisfaction questionnaires applied to the employees, between 2015 and 2018. CCEHO and TCECH are public utility units from two different counties (Bihor and Timis), located in the northwestern–western part of Romania (with about 175 km between them), with legal personality, having roles in providing medical services, functioning on the principles stipulated in the Law no. 95/2006, while being at the same time a basis of medical scientific education and research, which strengthens the quality of the medical act with respect to the patients’ rights, ethics, and medical deontology.

There were 885 beds in the CCEHO during the analyzed period (2015–2017) and 861 beds in 2018. The services were provided by 30 medical specialties, served by 8 laboratories and other departments of paraclinical investigations (imaging, pathological, etc.). At the same time, there were 1174 beds in TCECH, 30 medical specialties and one central laboratory.

The staff working in these structures consists of doctors, pharmacists, biologists, chemists, psychologists, and other senior staff, nurses, auxiliary staff, administrative staff, and support staff (workers, guardians). In the case of CCEHO, the number of jobs increased from 1923 posts in 2015 to 2076.5 in 2018; in 2018, the proportion of doctors in total staff was 13%, and the proportion of medical staff in total staff employed by the hospital was 64%. In the case of TCECH, in 2015 there were 2441 employees; due to the salary increase and because the working conditions improved considerably, the number of employees registered continuous growth; in 2018 there were 2565 posts, which represents an increase of almost 5%.

During the period of the study (2015–2018), a total of 4945 questionnaires were distributed to the employees of both hospitals, processed, and analyzed (Figure 1).

The employee satisfaction questionnaire (Supplementary Materials) did not suffer changes in the content during the mentioned period and included 25 points (the main socio-demographic data of the respondents: 1–3; observations/suggestions about the medical act and opinion about the questionnaire: 24,25; 20 specific items: 4–23), being structured into questions and information about the following:

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Employee motivation;

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The conditions of their activity;

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Professional development policy in the hospital;

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Direct-hierarchical superior-leadership, collaboration, and communication relationship;

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Respondent general data.

The questionnaires were applied to approximately 30–40% of the staff employed every year (in the first and second semesters), and were handed to respondents individually, under anonymity, after explaining the purpose of the research and emphasizing the confidentiality of the information. At the end of the questionnaire, the employee was asked to express any suggestions or dissatisfaction about the work done. The data were collected and interpreted by the statistical service and the analysis and possible measures required were carried out by the board of managers/directors of the hospitals.

During the period included in the study and in the context of the legislative changes regarding the salaries of the health workers, from the analysis of the results of the questionnaires, significant changes were observed only in the answers to 2 of the questionnaire items. Thus, in view of the purpose of the study, the employee satisfaction questionnaire selected those questions regarding the motivation and satisfaction of the staff. Only questionnaires with questions with “Yes”/“No” answers were included in the analysis. The employee satisfaction questionnaire selected those questions related to the motivation of the staff:

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Are you motivated? (question 1);

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Are you satisfied with working in this hospital? (question 2).

The tested hypothesis was as follows: wage increases and improved working conditions in recent years should positively influence employee satisfaction/motivation. The objective of this study was to explore the association between the satisfaction/motivation of the personnel in the health system, in the context of the salary increases, but also of the instability of the legislation in force regarding the remuneration of the personnel.

2.2. Statistical Analysis

For the statistical analysis, two different programs were used, namely Microsoft Excel for the descriptive part and SPSSv17 for the statistical tests. In order to test the data distribution, in each hospital and for the entire database a Kolmogorov–Smirnov test was applied. The chi-square test (χ²) (Pearson’s chi-squared test) was applied for the statistical processing. The test is used to determine the existence of a statistical difference between the expected frequencies and those observed between one or more categories. For cases where the sample size was low, the chi-square test was replaced with the Fisher test. A Mann–Whitney test was used for the numerical variables, α = 0.05 being considered as confidence level for the entire analysis.

3. Results

In the CCEHO, 2810 questionnaires were distributed, with annual average of 700, representing an average of 35% of employees interviewed annually. In the TCECH, 2135 questionnaires were distributed, around 550 each year, except 2015 when there were only 451 subjects. The data distribution for both hospitals are presented in

Table 1. Number of questionnaires distributed by the year and staff employed in the both hospitals.

Staff Employed	2015		2016		2017		2018		Total
	Sem. * 1	Sem. 2	Sem. 1	Sem. 2	Sem. 1	Sem. 2	Sem. 1	Sem. 2
CCEHO
Doctors	64	56	55	63	52	80	71	56	497
Nurses	81	183	188	195	171	175	181	199	1373
Auxiliary staff	72	100	94	100	91	114	109	103	783
TESA staff	11	19	19	20	12	21	27	28	157
Total/semester	228	358	356	378	326	390	388	386	-
Total/year	586		734		716		774		2810
TCECH
Doctors	43	41	42	44	47	55	53	40	365
Nurses	74	124	137	142	133	135	141	155	1041
Auxiliary staff	65	79	72	81	66	78	69	64	574
TESA staff	9	16	17	21	13	23	29	27	155
Total/semester	191	260	268	288	259	291	292	286	-
Total/year	451		556		550		578		2135

* Sem.—Semester.

.

For the CCEHO, the medical staff surveyed was 94.41% and consisted of doctors, nurses, and auxiliary staff (nurses, caregivers, guardians) in the hospital departments and services (laboratories, radiology and imaging, pharmacy). In the TESA staff category (technical–economic and administrative) were included non–medical staff (financial, accounting, procurement, technical–administrative, human resources, statistics, juridical department, computing office, quality management, etc.), which represented 5.85%. Of the total number of questionnaires (2810 questionnaires) 2645 questionnaires were validated (94.12%). The percentage of respondents with higher education was 43.02%, those with medium studies were 50.13%, and those with general studies were 8.43%. A percentage of 82.03% of questionnaires were filled in by women, and 17.97% were filled in by men (Figure 2a).

For the TCECH, almost the same percentages were obtained; the medical staff represented 92.74% (1980 subjects) and the TESA staff represented 7.26% (155 subjects). Out of 2135 questionnaires, only 2074 questionnaires were validated (97.14%). From these 2074 subjects, 1017 (49.04%) had high education, 974 (47.01%) had medium studies, and the rest, 83 subjects (3.95%), had general studies. Most of the employees (1532 (73.87%)) were females (Figure 2b).

In order to identify any significant differences regarding the average amount of subjects in both clinics, a Mann–Whitney test was applied for all four studied years. In all cases insignificant differences p > α = 0.05 resulted.

In the case of the first question, “Are you motivated?”, the average value of the motivation for the analyzed period was 86.38% in the first hospital and 92.10% in the second hospital. It is noted that the evolution of the staff motivation degree had an ascending trend until the first half of 2018 in the CCEHO and an almost continuous increase in the TCECH. In the first hospital the maximum degree of motivation (94.63%) was reached, followed by a considerable decrease to 79.14% for the second semester 2018. The motivation distribution in the second hospital had a maximum peak in the first semester of 2018 (96.28%). All the data are presented in Figure 3.

In the CCEHO, by type of staff, staff motivation had a linear growth trend for physicians and TESA staff. The nurses’ motivation had a rather steady evolution. Instead, for auxiliary staff the trend of motivation was decreasing. For all professional categories there was a decrease in the percentage of persons motivated in the second half of 2018 (Figure 4a). It is noted that the TESA staff had the highest percentage decline in motivation in the second half of 2018. The expected increase in motivation among doctors and nurses in the second half of 2018 was not observed. On the contrary, there was even a marked decrease compared to the same period of 2017. For the auxiliary personnel, the percentage of motivated persons in the second half of 2018 decreased both compared to the first half of 2018 and the second half of 2017. In the TCECH, for all the tested categories, in most of the cases, a slight increase in the motivation area was registered. This aspect can be explained from the economical point of view and as well, maybe, because this hospital in the past few years suffered from continuous renovation. The working conditions have evolved significantly for the better. The best values for motivation were registered in Semester 2 of 2017 (Figure 4b).

The changes noted above for each category of staff were also tested to identify whether they were statistically significant. The data were only analyzed for the second half of 2017, the first half of 2018, and the second half of 2018, because major wage changes took place during this period. The evolution of the number of staff respondents answering that they were motivated in the last three semesters is presented in

Table 2. Motivated staff: semester 2, 2017—semester 2, 2018.

Are You Motivated?	Sem. 2			Sem. 1			Sem. 2			Statistical Significance
	2017			2018			2018
Employees	Total Subjects	Responses		Total Subjects	Responses		Total Subjects	Responses		p Values
		Yes	No		Yes	No		Yes	No
CCEHO
Doctors	69	64	5	64	59	5	53	45	8	>0.05
Nurses	160	152	8	170	165	5	155	125	30	<0.00001
Auxiliary staff	95	77	18	94	86	8	93	70	23	0.012
TESA * staff	21	21	0	26	25	1	25	18	7	0.0026
TCECH
Doctors	52	49	3	49	46	3	38	35	3	>0.05
Nurses	126	122	4	138	133	5	151	146	5	>0.05
Auxiliary staff	72	64	8	66	58	8	62	54	8	>0.05
TESA staff	19	17	2	24	22	2	25	23	2	>0.05

* Technical, Economic and Socio-Administrative staff.

.

In the case of CCEHO, the chi-squared test for the Yes and No answers of doctors was applied, obtaining a value of p = 0.29. The degree of motivation among physicians decreased but was not statistically significant for the second semester 2018 (84.90%) compared to the first semester 2018 (92.18%) and the second semester 2017 (92.75%).

A chi-squared test was applied for the Yes and No answers of nurses, obtaining a value of p < 0.00001. A statistically significant decrease of the degree of motivation in the second semester of the year 2018 (80.64%) was confirmed compared with the first semester of 2018 (97.06%) and second semester of 2017 (95%). The percentage of auxiliary staff declaring that it was motivated decreased from 81.05% in the second semester of 2017 to 75.26% in the second semester of 2018. A chi-square test was applied for the Yes and No responses and p = 0.012 was obtained. A statistically significant decrease in the level of motivation among auxiliary staff was confirmed. A Fisher test was applied for TESA Yes and No responses and p = 0.0026 was obtained. A statistically significant decrease in TESA staff motivation for the second semester of 2018 (72%) compared to the first semester 2018 (96.15%) and second semester 2017 (100%) was confirmed. In the case of TCECH, insignificant differences in all tested scenarios p > α = 0.05 were obtained. Some differences could be seen, but they were not statistically significant.

In the case of the second question, “Are you satisfied with the fact that you are working in this hospital?”, the average satisfaction level of the respondents was 96.95% in CCEHO, and 97.78% in TCECH. The Yes responses had an upward trend in the period 2015–2018 (Figure 5).

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The percentage of people satisfied with working in each hospital had a linear growth trend with a preservation of over 98% for the last three semesters analyzed. In all professional categories, the degree of satisfaction had an ascending evolution. The category of staff that was least satisfied with working in CCEHO consisted of doctors. However, there was an increase in satisfaction to over 96% over the past two years.

→

For the last three analyzed semesters (2017–2018), the percentage of those satisfied with their work in CCEHO had a relatively constant evolution (

Table 3. The evolution of satisfaction: semester 2, 2017–semester 2, 2018.

Are You Satisfied?	Sem. 2			Sem. 1			Sem. 2			Statistical Significance
	2017			2018			2018
Employees	Total Subjects	Responses		Total Subjects	Responses		Total subjects	Responses		p Values
		Yes	No		Yes	No		Yes	No
CCEHO
Doctors	71	69	2	64	62	2	52	50	2	>0.05
Nurses	171	169	2	173	170	3	188	184	4	>0.05
Auxiliary staff	108	107	1	101	101	0	92	88	4	0.044
TESA staff	21	21	0	27	27	0	26	26	0	>0.05
TCECH
Doctors	53	50	3	49	48	2	37	36	1	>0.05
Nurses	131	124	7	135	132	3	145	141	4	>0.05
Auxiliary staff	72	68	4	66	64	2	61	60	1	>0.05
TESA staff	20	19	1	25	24	1	23	22	1	>0.05

).

For CCEHO, the statistical significance was tested using the Fisher test. Only for auxiliary personnel was there a decrease in the limit of the statistical significance (p = 0.044) of the number of those who responded that they were satisfied. For TCECH, the differences observed between the tested years could not be considered significant from the statistical point of view p > α = 0.05. The dissatisfactions generated by wage changes were not reflected in the respondents’ answers to the question, “Are you satisfied with working in this hospital?”.

The last hypothesis that was tested allowed us to see if there were significant differences in the motivation/satisfaction area of our subjects between the two studied hospitals. In this regard, the Chi square test for proportions was applied and extremely significant differences p < 0.001 were obtained in the motivation area in the last semester of 2018. The personnel from TCECH were significantly more motivated.

4. Discussion

The essential role of investments in health as well as in the workforce from the healthcare field for continuous development has been demonstrated by the recent global policy initiatives, through simultaneous approaches of different objectives of sustainable development, highlighting the integrating force of consolidation for the health sector. To solve efficiently the lack of labor force in the health system, investments and a stable legislative frame are required, not only the supplementing of the personnel number [32,33].

For the two hospitals included in this study, an important component of the overall objectives set is to achieve work satisfaction by building a motivational climate. The motivational policy of the hospital is based on the identification and activation of employees’ motives, using a number of appropriate incentives; furthermore, the management of both hospitals must be focused on finding and implementing the best methods to stimulate employees, regardless of the legislative conditions regarding the level of payment. Material incentives in the public health system are predominantly based on wages, but hospital employees also benefit from protective equipment, service telephones (management employees), and some products or services provided free of charge under the legislation or collective labor agreement. Non-material incentives in the hospital include professional training, public recognition of merit, appreciation of results through praises or diplomas, collaboration, and direct communication.

Investments in the structure, rehabilitation of working spaces, and endowment with medical equipment and high technology equipment, correlated with the specific training of the employees, have been elements that increase the satisfaction of the employees.

The results of the hospital strategy and policy are also assessed by employee satisfaction, which determines the motivational factors, needs, and expectations that employees have at their workplace. An objective analysis highlights the extent to which the employee is satisfied at the workplace, determining the hospital management to develop measures to increase employee satisfaction.

Nowadays, managers have to consider job satisfaction as one of the most important issues related to their employees. Several studies highlighted the influence of job satisfaction on the workers’ motivation, pointing out the impact that motivation has on productivity as well as on the business organization performance [5]. The satisfied workforce is a necessary condition for the efficient functioning of a health system. Every year more frustrated professionals give up their profession or their jobs looking for better chances, many of them leaving the country. Due to this reason, recently, satisfaction at the workplace, in the sector of public healthcare and also of human resources, became important in Romania. Our research focuses on the satisfaction/motivation of the workers in the public health/healthcare system in Romania, in the context of the frequent and numerous changes of the legislation (in the period 2015–2018) regarding the remuneration of the staff existing in the sanitary facilities/services. For the years 2015–2017, Law no. 284/2010 established the salary and other healthcare employees’ rights as follows:

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By Emergency Ordinance (EGO) no. 20/2016 for amending and supplementing the Government Emergency Ordinance no. 57/2015 on the salaries of staff paid out of public funds in 2016 [34,35], starting from August 2016, the basic salaries of the staff in the sanitary units are increasing, the rearrangement of the staff being made on functions, grades/professional steps, and grades corresponding to the length of employment according to the normative act; the provisions of the law have benefited the superior, medium, and auxiliary medical staff, as well as the staff employed in leading positions; the same normative act regulated that the guards of high-qualified health personnel, outside the legal norm of work and the normal work schedule of the basic function, are carried out on the basis of a part-time contract for the work done in the line guard and staff will only benefit from the rights related to the on-line duty.

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Government Emergency Ordinance no. 43/2016 amending and supplementing Government Emergency Ordinance no. 57/2015 [36], starting in August 2016, staff paid from public funds receiving a basic salary/salary allowance corresponding to a normal working time schedule lower than the one set in payment to the maximum for each function, degree/step, gradation, seniority or specialty, as the case may be, will be paid to the maximum level of the basic salary/indemnity allowance within the respective institution or public authority, if they carry out their activity in the same conditions; these provisions have benefited the technical and administrative staff and the working staff; by the same normative act from October 2016, for guards performed by healthcare personnel with higher education outside the legal norm and the normal work schedule of the basic function, the hourly rate is determined by the basic salary provided in the normative act corresponding to the execution function.

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Law no. 250/2016 regarding the approval of Government Emergency Ordinance no. 20/2016 for amending and supplementing the Government Emergency Ordinance no. 57/2015, introduces new provisions of the basic salaries of staff in sanitary units starting in December 2016 [37].

The salaries of the public workers in 2018 were made in accordance with Law no.153/2017 on the remuneration of staff paid from public funds [20]:

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Starting January 1st, 2018, doctors and nurses benefit from a 25% increase in wages compared to December 2017; starting March 1st, 2018, the basic salaries of staff occupying the positions of doctors and nurses in public health establishments increased to the basic salary level of 2022; for the remaining categories of staff, wages will be increased gradually until 2022, when they reach the base wage corresponding to the salary scale.

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Law no. 153/2017 provides for a maximum level of the allowances granted in the health and social assistance system to 30% of the amount of the basic salaries at the level of the main credit officers.

Substantial changes in the salaries of hospital staff were brought about by Law no. 153/2017. Legislative provisions and how to enforce the law determined, between March and April 2018, staffing grievances, managed by hospital management through frequent work sessions with a view to correctly communicating law enforcement. Discontents concerned the following:

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All staff due to changes in the increase for specific conditions related to each job; all bonuses have reached the minimum required by law, due to the legal provisions for maximum bonuses to 30% of the basic salary, at the level of the main credit officers.

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Nurses, auxiliary personnel, and non-medical personnel whose, by the provisions of the Regulation of bonuses approved on the basis of article 23 of this law, net wages in March 2018 were lower than those granted in February 2018.

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Pharmacists, chemists, biologists, auxiliary personnel, and TESA staff who will reach the statutory salary only in 2022; except for doctors and nurses.

Some of these dissatisfactions were subsequently regulated by the Government through the Law Enforcement Provisions, so that beginning with May 2018, if the net salary incomes were lower than those for February 2018, a compensatory amount was given with temporary character in order to cover the difference.

Announced with intense media coverage, wage increases in the healthcare system have led to major hopes for health workers. Unfortunately, for many categories of staff, wage growth was insignificant. Against this backdrop of general dissatisfaction with the law enforcement, differentiated by categories of staff, a series of informal communication channels emerged within the hospital, which generated a poor communication that in many cases resulted in the emergence of conflicts. In the period immediately following the wage increase, inter-social relations were altered in most hospital wards, departments, and compartments, while the motivation of the hired personnel declined.

Although payroll is a component of professional motivation, in this case, it has prevailed over all other components, pay being not only a consequence but also a premise of an efficient activity.

Individually, wage increases have led to an increase in employees’ satisfaction, but in the organizational plan, wage increases have had unexpected effects, by lowering the motivation of employees. Although the duties and tasks of each category of staff are well defined, the delegation of tasks, usually from upper to lower staff, leads to the appearance of dissatisfaction, which subsequently degenerates into conflicts. The motivation of human resources in health is the result of a series of decisions and actions that determine the personnel to contribute directly or indirectly to the achievement of the quality of the medical act, based on the correlation of their interests in the approach and achievement of the hospital objectives. Thus, staff motivation must be approached from two perspectives, firstly managerial, and secondly from the employee perspective [38]. The motivation methods adopted do not solve the problem of motivation, because for employees, a method that once motivated the employee after a while can become natural and no longer of interest. For example, in the hospital under consideration, improvement in endowment, conditions, and safety and protection measures at the workplace, payment by the hospital of courses, training, and professional development have no longer been relevant when employees have been paid differently; for physicians and nurses, the salary increase was granted on March 1st, 2018, and for the rest of the personnel categories the salary increase will be completed only in 2022.

Employees feel more motivated if they work in an environment where they are appreciated for what they are doing. These discrepancies in the wage increases have been perceived differently by employees, specifying that the government does not recognize the importance of the work done by all staff in the hospital, this unpleasant experience demotivating employees. Salary is perceived by the employee as a “right”, and the motivational effect is based more on the “fear of losing it” than on the desire to “do more and better”. The big differences between the incomes of Romanian and EU medical staff, and the fact that in recent years the governors have promised wage increases on a level similar to those in the EU, has led to the emergence of financial expectations of employees, expectations that were not met.

The external factors that can influence the motivation of the staff, in this case the legislative changes of the salary, must be handled with great care, through efficient collaboration and communication and direct relation, given also that the financial motivation has an effect for a short period of time compared to non-financial motivation. Therefore, the emphasis should be on the non-financial incentives of highly qualified medical staff, such as improving working conditions, performant medical equipment, training opportunities, responsibility, and quality of service.

The decrease in employees’ motivation did not affect the overall satisfaction of employees; declaratively 96.95% of employees were satisfied with working in the hospital, appreciating the radical changes in working conditions and organizational climate made in recent years.

Most of the literature data in the field focus on the satisfaction of only one medical professional category (most on physicians or nurses) and far fewer include all categories of employees in the public health system. This study extends the research area, investigating the state of job satisfaction/motivation of all categories of employees existing in public hospitals as a whole; furthermore, it has an important contribution to the literature from the healthcare domain by revealing and evaluating the satisfaction/motivation status of workers in the medical and non-medical domain, in the context of the salary increases and the instability of the legislation in force regarding the remuneration of the personnel.

The present research used comparative and qualitative analysis to explore the association between the satisfaction/motivation of the employees in the health system and the wage changes of the last years. This association was based on the analysis of only two items (namely those that measure the existence of satisfaction/motivation), and their approach is with dichotomous answers (“yes” or “no”), which is one of the limitations of this study. Another limitation is determined by the fact that this follow up study eliminates the causal analysis, relying only on self-report, a fact that could determine socially desirable responses and thus does not represent a causal relation between the studied variables. Regardless of these limitations, this is the only study of its kind in Romania in the context of implementing the Multi-Annual Plan for the Development of Human Health Resources [19]. As well, the present study has an important contribution to the literature from the healthcare domain by revealing and evaluating the satisfaction/motivation status of workers in the medical and non-medical domain, in the context of the salary increases, but also of the instability of the legislation in force regarding the remuneration of the personnel. The healthcare policy makers, managers, or other individuals with political and management power can acquire better understanding of the issue concerning the ideas for improving human health resources in administration practice, especially in Romania, where managerial fluctuations in the medical field have a high dynamic.

We hope that in the future, our study will be extended, including more variables that affect hospital staff work satisfaction/motivation.

5. Conclusions

The healthcare wage increases in the health system in 2018 should have had a positive effect on the motivation of hospital employees, especially regarding doctors and nurses, but in the latest analysis of employee satisfaction has been noticed, at some categories of staff from various structures, a decrease in motivation. With the exception of doctors, for the rest of the staff, the degree of motivation decreased statistically in one of the two hospitals included in this study. An important conclusion is that in recent years, non-financial motivation reinforced by proper management in the hospital has led to a general degree of employee satisfaction.

Employee motivation remains an important issue in the general hospital policy, the study highlighting the fact that non-financial and financial motivation are important for the employee in the healthcare system. In the current instable legislative context, the financial motivation cannot be influenced by the management of the public hospital; therefore, other appropriate measures are required to increase the satisfaction of the employees (good working conditions, facilities at work, pleasant and comfortable working environment, etc.).

Our results highlight the need to reevaluate policies that could perpetuate inequalities in the field of salaries in Romanian hospitals, as well as a signal to promote strategies that increase satisfaction/motivation among all categories of employees from hospitals. To reduce the risk of dissatisfaction of the medical personnel and also to enhance their feelings of belonging at work and also their happiness, in order for them to provide high quality services to patients, the management of the medical institution and the decision-makers in the field of healthcare should focus on the bonuses at the workplace and practicing environment. Even so, more upgrading and developments should be performed in the healthcare domain and related services.