Determining the Characteristics of a Healthy Environment Promoting the Health of Women Working in the Hospital: A Qualitative Study

doi:10.21203/rs.3.rs-2635694/v1

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Determining the Characteristics of a Healthy Environment Promoting the Health of Women Working in the Hospital: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-2635694/v1

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Background and Purpose: The workplace is one of the priorities for health promotion in the 21st century by extending as the adult population extends. Also, the work environment has a significant impact on people's health. Therefore, the aim of this study was to determine the characteristics of a healthy environment promoting the health of women working in the hospital.

Materials & Methods: This study was conducted using a qualitative method and content analysis. The participants were selected using the purposive sampling total of 48 working women, hospital managers, and health promotion specialists participated in the study. In this study, we tried to select participants with maximum diversity in terms of age, work experience, and the sector they are working in. The data were collected using a semi-structured interview. The texts of the interviews were extracted and divided into the meaningful units. The criterion of credibility or acceptability of the data (Credibility) was used to ensure the accuracy of the study results.

Results: In the process of data analysis, 31 basic concepts that had the same characteristics were grouped into 12 subcategories, and based on the common characteristics at a more abstract level: they were transformed into 3 main categories, including organizational management and commitment to the health of working women. The psychological environment supports women's health, and also the social environment promotes women's health in the hospital by providing services.

Discussion and conclusion: Hospital managers play an important role in creating healthy workplaces for women, and to achieve this goal, they should try to improve their health from the aspects of mental and social health and provide special services to working women.

Healthy hospital

Health promotion

Working women

Healthy workplace

The workplace is one of the priorities for health promotion in the 21st century as the adult population extends [1]. It is therefore important to create a healthy workplace. Given that many workplaces implement health promotion programs for their employees; this suggests that some employers feel they have a role in creating healthy workplaces [2].

Studies conducted in a large number of societies have shown that women are an important factor contributing to the growth and development [3]. Generally, this role of women has been neglected in local and regional planning, and also women's daily activities are considered normal and have no special structural impact. Women have been viewed as passive actors in the process of human evolution. This may be due to the participation of women along with men in all issues showing the acceptance of the equality of human value of all members of the society, who cooperate in various matters, and through that, they transform and create positive changes, which can be useful for the future of the whole society [4, 5]. As stated in the second health promotion conference in Adelaide in 1988, women are the first health promoters in the world and most of them work without salary or with the lowest wages, and on this basis, policy makers and institutions should pay more attention to women and support them [6].

On the other hand, in the last few decades, the number of the economically active women has dramatically increased in developing and developed countries [7]. Due to increasing the activity of women in the workplace, during the past decade, studies conducted on a healthy workplace have been severely criticized for not having a gender perspective, leading to the exclusion of women and their concerns. [8]. Researchers have not been able to include women in studies, and also gender and sexual factors are often not considered when designing studies and analyzing the data [9].

Hospital is one of the settings for health promotion. Hospitals and other healthcare centers, like an industrial unit, consist of production factors, such as capital, manpower, technology, and management, which take steps to promote the health of nurses, doctors, and the human resources of these centers and women are also the main providers of health services at different levels. Healthcare workers especially women are exposed to high levels of occupational stress due to heavy workloads, long working hours, and high time pressure. Healthcare workers, including doctors and nurses, are at greater risk for depressive disorders than the general population. The risks related to long working hours have been proven by doctors and interns [10].

In recent studies, night shift, which is one of the main components of working in the healthcare environments, has been identified as an effective factor in breast cancer. Studies also confirm that cancer assessment and monitoring of exposure to carcinogenic substances as well as occupational diseases are still being investigated in occupations related to men and focus on men's exposure to hazardous substances [11]. In addition, shift work has the potential to disrupt family and social life and can cause chronic fatigue, sleepiness, and physical symptoms; however, it is often against the rhythmic timing system of ordinary people [12]. Considering the more roles that women have in the family and society, these types of jobs create more and more intense conflicts between roles for women. Such conflicts place multiple duties on women and raise new issues for her. Therefore, if women face problems in balancing their work and family roles, they will experience conflict between work and family, the consequences of which will not only affect the individual, but also the organization and, at a higher level, the society. They will not stay away from these problems [5]. On the other hand, many MSD problems experienced by women in the workplace may be aggravated; therefore, work equipment (such as factory desks, chairs, and benches) is designed to meet the ergonomic needs of the average man. Gender insensitivity to the plan designed in the workplace can lead to the frequent injuries among female employees, and thus this is a very important point of attention for healthcare managers and professionals in the workplace [13].

Given that creating a workplace that is effective in promoting women's health has different aspects and addressing it requires explaining the understanding of work environments like hospitals and the views of people providing services in these environments; therefore, the aim of this study was to investigate some factors affecting the creation of a workplace promoting the health of women working in the hospital.

The semi-structured interview was the main method of data collection in this study. In this research, the interviewer was a PHD student in health education and health promotion who had a history of participating in qualitative research workshops and was fully familiar with the subject. Before conducting the interview, the interviewer introduced himself to the participants and got an appointment from them to conduct the interview. Also, he had a neutral role and behaved friendly, and tried not to express his opinion in the interview.

The participants in this study consisted of women and managers working in one of Tehran's hospitals and health professionals who were selected using the purposive sampling with maximum diversity in terms of age, work experience, and position in the desired department.

A total of 48 female employees, supervisors, and ward managers of a hospital in Tehran, as well as specialists in the fields of health promotion, a healthy workplace promotion, and professional health aged 24 to 50 years participated in this study. Also, to increase the validity of the data, we tried to use the maximum diversity of the population. There was no need to renew the interview in any of the conducted interviews. The data were collected at the workplace of the participants and usually at the employees' resting place without the presence of anyone other than the interviewer and the participant. A voice recorder was used to collect the data and field notes were taken during and after the interview. In this study, the data were collated using a semi-structured interview, so the interviews were conducted face-to-face.

The interview was started with general questions: what kind of work environment do you think can improve women's health? And then the next questions were raised; In your opinion, what are the dimensions and features of a workplace that promotes the health of women working in a hospital? What can the hospital do to promote women's health at work? In your opinion, what are the indicators of a workplace that promotes the health of women working in workplaces like hospitals? To know more about the subject, other exploratory questions were also asked according to the participants’ answers. Field notes during interviews and observations were also used in the data collection and analysis. Each interview lasted for 20 to 30 minutes. In the interviews, a summary of the interviewees’ statements was read to the individual to comment and give feedback on the accuracy of their statements. Some interviews were also returned to the participants to provide feedback on their statements. Data collection continued until data saturation was reached and no new data were obtained.

In this study, the conventional content analysis method was used. This method helps researchers have a deeper understanding of a phenomenon. Data collection and analysis in this study were performed simultaneously and continued until no new code was obtained. A voice recorder was used to conduct the interviews, and also each interview was transcribed verbatim in a Word file. Then, the interview texts were checked by two members of the research group and read several times to get a complete understanding of the data and their concepts. According to the content and text, the sentences and paragraphs of the interviewees were considered as the smallest units of analysis and the primary codes. Then the codes were sorted into subgroups and categories by comparing their similarities and differences. In the end, the main class in which the subgroups were placed, expressed the content and concepts hidden in the texts[14].

Ethics approval and consent to participate: This study was approved by the Research and Ethics Council of Iran University of Medical. Sciences (code: IR.IUMS.REC.1398.201). all methods were carried out in accordance with relevant guidelines and regulations Written informed consent was obtained from all participants prior to taking part in this study. To comply with ethical considerations, before conducting the interviews, the participants were informed about the purpose and necessity of conducting this study, and also the written informed consent was obtained from all participants. In addition, to respect the rights of the participants, the necessary arrangements were made to interview them, and also an earlier time was arranged with them. In addition, permission was obtained from the interviewees for audio recording, and before conducting the interviews, the purpose of the research and how to collect data were explained to them. To ensure the confidentiality of the information and obtain their participation before conducting the interview, the participants completed an informed consent form to participate in the project. Then the participants were assured that the interview will remain confidential, with the research team, and in a safe place, and if they did not want to continue cooperation, they would have the right to refuse to continue the research.

The validity and strength of the data obtained in this study were considered through Goba and Lincoln's criteria [15]. Validation was achieved by reviewing the manuscripts by the participants and the researcher's long-term engagement with the research area and the participants. Confirmability was established by maintaining the impartiality of the researchers, reviewing the extracted codes and classes by two members of the research team and reaching an agreement. Along with in-depth, semi-structured interviews, secondary methods, such as observing and recording field notes during interviews, were also used to strengthen the data. The reliability or consistency of the findings was ensured by typing and analyzing the interviews as soon as possible, using the opinion of colleagues specialized in qualitative research and experts in the field of health promotion in the workplace, and rereading the entire data. The conveyance was also made possible by the provision of many direct quotations and data-rich explanations[14].

The demographic information of the study participants is shown in Table 1. The health-promoting environment of women working in the hospital was graphed as the central variable. In the process of data analysis, 31 concepts that had the same characteristics were converted into 12 subclasses, and then, based on common characteristics, at a more abstract level, they were converted into 3 main classes.

Table No 1: Demographic characteristic

		Number (percent)
Age	Less than 25	2(4.16%)
	26-30	18(37.5%)
	31-40	17(35.41)
	41-50	6(12.5)
	Above 50	1(2.08%)
Hospital work experience	2-10	21(43.75%)
	11-15	6(12.5%)
	16-20	9(18.75%)
	Above 20	8(16.66%)
Current workplace section	Men's surgery	2(4.16%)
	CCU	7(14.58%)
	Radiology	3(6.25%)
	Dialysis	3(6.25%)
	ICU	4(8.33%)
	Education	2(4.16%)
	Internal	2(4.16%)
	Emergency	4(8.33%)
	Women's Surgery Department	6(12.5%)
	NICU	2(4.16%)
	Employee	4(8.33%)
Health specialist	Health promotion specialist	3(6.25%)
	Occupational specialists	2(4.16%)
	Women consultant	3(6.25%)

Category	Subcategory	Code
Management and commitment to the health of women working in the hospital	Practical support of the hospital for women's health	Facilitating policies to promote women's health
		Considering women's health in hospital programs and processes
	Human resource development	Meritocracy
		Honoring the status of women
		Human resource management according to the position of women
	Organization of the hospital work environment	Organizing teamwork in hospital departments
		Establishment of hospital work management systems
	Facilitating organizational relationships	Management style promoting women's health
Psychological environment supporting women's health at work	Women’s occupational satisfaction	Attention to the satisfaction and psychological security of women
		Improving the desirability of the hospital work environment
	Work-life balance for women	The hospital's support for the family conditions of working women
		Empowering women in adjusting work-life interference
	Reducing women's occupational stress	Creating conditions to damping women's job burnout
		Designing programs to improve the morale of women working in the hospital
Social environment supporting women's health in the hospital	Professional solidarity and cohesion	Planning and development to promote positive interaction between employees
		Developing positive working relationships between managers and employees
		Development of social support of colleagues
	Security of the hospital environment for women	Preventing managers from horizontal violence against women working in the hospital
		Attention to the prevention of violence against women by patients and companions
		Providing social security for working women in communication with colleagues
		Attention and provision of economic security for women working in the hospital
Providing women's health promotion services	Occupational health and safety in hospitals	Paying attention to ergonomics suitable for women's conditions
		Planning and ensuring the safety of the hospital work environment according to the characteristics of women
		Providing a healthy workplace for women in hospital conditions
	Women's health-promoting care	Providing the conditions and specializing periodic tests and examinations of women
		Planning and developing physical activity in the hospital according to working and family conditions of working women
		Attention to healthy nutrition and healthy food for working women
	Welfare facilities suitable for women's conditions	Providing childcare facilities for women working in the hospital
		Attention to the welfare and health of working women and their families
		Provision of comfort facilities outside the hospital for women

1. Management and commitment to the health of women working in the hospital

Practical support of the hospital for women's health

Facilitating policies are actually decisions that can have a significant impact on women's health in workplaces like hospitals. Adopting policies to promote women's health in the hospital in cases such as the presence of women's representatives in health promotion decision-making committees and the establishment of rules and regulations within the organization according to the conditions and surveys can help hospital managers meet the needs and priorities of women and create a healthy workplace for women working in the hospital:

For example, the one who said cell phones are prohibited, sitting in a room with a closed door, a nurse was not with him, a mother who is a nurse was not with him, sits in a meeting and says cell phones and you prohibit them, my child is alone at home and wants to call me, tell me his situation...

On the other hand, the visibility of women's health in the hospital's policy, and when developing the internal regulations of the hospital, as well as the visibility of women's health in the operational and strategic plans of the hospital can help managers focus on this important issue. As the study participants reported, updating women's health policies in hospital programs is vital so that the hospital can achieve this goal:

"Well, we can say that in Adelaide's statement, this issue has been mentioned exactly. In the workplace, at least if it is not separate in the policy, health issues and now women's issues should be mentioned in the policy..." workplace health promotion specialist)

For this reason, I say a systemic view and these differences should be taken into account. Otherwise, you cannot have a written program for your collection, and this must exist in hospital processes... (health promotion specialist, university professor)

Human resource development

In this study, human resource development (HRD) was emphasized the problems and issues faced by women, including meritocracy, respecting women’s rights, and human resource management (HRM).

Communicative competence and achieving meritocracy in the workplace were among the factors that the participants reported. ... A manager having a correct understanding of the problems and issues faced by working women could contribute to creating a healthy workplace for women in the hospital:

If we can have an indicator, a criterion, at least one person in the workplace, who monitors the manager or the boss, provided that he is healthy and understands the issues and problems faced by women, then this can affect the efficiency of working women (Female, 47 years old, nephrology specialist, 9 years of work experience).

Respecting women’s rights, including concepts such as fair material rights of women, fair allocation of resources, equal job opportunities for women, respecting women's position, and the use of women's capacities in management fields are among factors that the participants reported . It has been stated that it is effective for women's health in workplaces. The existence of male structures causes discrimination between men and women and sometimes causes job opportunities created for women and men to be unequal and most men are placed in management positions; however, the presence of women in management ranks can help both the system and understanding the problems faced by working women and solving them.

Unfortunately, there are mostly male structures in our hospitals, I say that these should be broken and areas for growth should be created, and also equal job opportunities should be given to women. (Health promotion specialist, professor of education and health promotion, university faculty member)

Human resource management

Hospital managers paying attention to the empowerment of women in various fields can get more success in creating the healthy work environments for women. From the point of view of the participants, improving women's skills (such as negotiation skills, increased self-confidence, managing roles, and being bold), empowering them in managing and self-care of different periods of fertility at work, improving women's job skills, conducting fertility course management training, women's participation in hospital health promotion programs and forming women's health self-help groups can help create a healthy work environment for hospital managers.

"More than all of this, you can work in the field of empowerment, and increase their courage., This will help them grow in the system" (Mr. Health Promotion Specialist, Professor of Education and Health Promotion)

2. Psychological environment supporting women's health at work

The results of this study demonstrated that the scope of the psychological environment supporting women's health at work included women's occupational satisfaction, and establishing a work-life balance for women.

Women’s occupational satisfaction

The study participants reported that improving the perceived psychological security of women at the workplace could create confidence in them so that they can work and provide services in a calmer environment away from additional stress and perceived psychological pressure. In addition, constructive handling of mistakes and errors at work, managers' understanding of women's work and family conditions, financial and economic support for women in the unfavorable economic conditions, organizational promotions and their fair management, creation of career incentives and encouragements that managers to create the motivation used by women were factors affecting their perceived satisfaction and psychological security, as the participants reported.

Negligence and mistakes have nothing to do with the patient, he just wants a service... by the way, somewhere the nurse has to come and answer. But what is important is to be reminded in a healthy and stress-free environment, and in my opinion, this environment is more informative (female, 48 years old, supervisor, 24 years of work experience).

When I want to retire, if my husband does not support me, I have nothing of my own. I came here when I was 24 years old, and I have been working here for 24 years. But I don't have anything for myself (48-year-old nurse)

Employees, especially women, should be motivated to work. Be encouraged for the positive work you do one day, even the simplest work, when you are encouraged, you will find motivation and you will do it many times in the future. (Female, 28 years old, nursing expert with 3 years of work experience)

Improving the desirability of the hospital work environment

Many participants reported that the presence of a calm environment away from additional tensions, the beauty and freshness of the workplace, and the provision of the necessary equipment to have a favorable work environment could contribute to relaxing and improving their working conditions. According to them, therapeutic work environments like hospitals could bring many tensions to them, and also additional tensions could affect their health, especially their mental health. Also, the desirability of the physical work environment can reduce their tension:

The first thing is to be calm in the work environment. When your environment is calm, your mental health is ensured and you can think and make decisions better. (Head of the women's ward, 40 years old, 15 years of work experience)

... For example, a small change in the women's resting place will improve their mood. Every once in a while, if they buy a flower for their workplace, make a small change in the space, it might have an effect and change their mood, for sure.

The hospital managers can sometimes make a happy program and gather the staff, for example, a happy program will be held in the amphitheater hall (29-year-old lady, in charge of education, 5 years of work experience)

Work-life balance for women

, The participants believed that work-life balance for women was one of the most important factors affecting all aspects of life (work and family) of women working in the hospital. The multiple roles that women have in the family, society and workplace can be in conflict with each other and cause problems for them. In order to establish a balance between work and life, women working in workplaces like hospitals need support from different people, such as hospital managers and families, and on the other hand, many of these women have to cope with this conflict and the pressure of different roles, and accordingly, they need training and empowerment.

The hospital's support for women's family conditions is one of the most important factors contributing to work-life balance as the participants reported. For example, flexibility in the time and workload of pregnant women can help them reduce the risks caused by work pressure and pressure of social roles:

A woman who is pregnant surely has problems, and she cannot easily do all the work with a lot of pressure; this pressure will definitely harm her. The system can work more flexibly for pregnant women.

On the other hand, family problems faced by personnel, such as taking care of children and babies under one year old, mothers who have children with special problems and taking care of them could create conflict in their family and work roles were also reported by many participants:

When the hospital provides conditions and facilities for women to take care of children, obviously women can come to work more easily, and they can take care of their problems at home more easily. Monet (female, 28 years old, a nursing expert with 4 years of work experience)

Many women working in hospital workplaces face problems, such as not accepting night shifts or working on holidays with their husbands. Some participants reported that night shift, and working on holidays can disrupt women's family life; however, the cooperation and support of managers and officials, such as the head of the department and supervisor in their work arrangement until these family problems lead to appropriate solutions and a balance is established in their work and life, can create a calm environment away from tension. Also, their work-life balance showed a significant impact:

The people who work here are married, many of them have husbands who are not nurses and have other jobs. Therefore, it is difficult for them if their spouses work at night or on holidays, and management by being aware of these problems and creating a supportive environment in these conditions can reduce many of these problems. (Ms., CCU supervisor 45 years old, 20 years of work experience)

3. Social environment supporting women's health in the hospital

Professional solidarity and cohesion include the development of positive employee interaction, positive working relationships, and the development of social support for colleagues.

The study participants reported that non-discrimination between employees' work, management of organizational improvement, collaborative solution of departmental problems, management of employees' respect for each other and the creation of effective horizontal communication, positive working relationships between managers and employees, the development of social support from colleagues and creation of support facilitation tools were the most important factors contributing to professional solidarity and cohesion. When the organizational promotion is fair and away from any informal relationships and according to the rules, the feeling that there is no difference between the work of female employees and the work of all people is seen without any discrimination, when the problems created can be solved by the positive interaction between the managers of the department and the desired unit and the employees and women, and effective communication between colleagues and respect between them creates an atmosphere that can provide women's peace in the atmosphere full of stress and tension in the hospital.

Career promotion is very important here. In a country like Japan, your colleague tells you to give me your hand so that I can take you higher, so I myself go one step higher. But this is not the case here, either they push you down or they are so pessimistic towards each other that if they are on the same level, they are still jealous of each other (38-year-old female, nurse expert, head of NICU department).

I like very much, when there is a problem between me and my colleague, we solve it ourselves and it is not taken to the office of the director or nurse, because our job has enough margins (26-year-old woman, nursing expert with 4 years of work experience).

The manager is like the mother of the family, he can make the atmosphere very good, he can calm the atmosphere with the management he does, he can make the children all get along well. (Female, 47 years old, nursing expert with 24 years of work experience) ...

Security of the hospital environment for women

Workplace security for women is one of the most important factors creating a healthy workplace and promoting women's health. The participants considered it as the most factor important contributing to safety of women in the workplace, both physically and psychologically, including the prevention of horizontal violence, organizational coercion, violence perceived by patients and companions, and provision of both social security and economic security.

An unreasonably high volume of work, forced shifts, forced placement in different departments of the hospital, low salaries and benefits for a lot of work, inappropriate workplace, workplace stressors, and lack of facilities are among factors that can be considered as organizational coercion (Vertical violence). It involves staff and nurses, and can be noticed by managers. Many participants reported that these cases as harassment might not receive much attention, but these organizational problems could also affect the quality of work life of these employees:

"Unfortunately, there is a heavy workload that when you go home, you are tired and you carry all the anger and violence that you saw at work home..." (female, 28 years old, a nursing expert with 3 years of work experience)

In our work, overtime is compulsory, I don't want it, but our job is compulsory and I have to come to work every hour. (Nursing expert lady, 42 years old, 18 years of work experience)

Violence inflicted by the patients and their companions

Physical and verbal violence between the patient and his/her companion, verbal violence between the colleagues, the physical violence between the patient and his/her companion can be caused by factors, such as lack of facilities and power and as a result, the quality of service is reduced, or the death and discomfort of the patient, and the worry and stress of the patient's companion. It is the patient's condition that puts the nurse, doctor, paramedic, and hospital staff in danger; among the things mentioned:

We have cases where as soon as the patient comes in, he breaks the glass, throws files, throws anything he can get..." (MS. Supervisor, 48 years old, 24 years of work experience)

The companion is very agitated and angry, and they curse the patient for not being stable. She sees her patient's family dying and is angry and vents all her anger on the female nurses who have no support..." (MS, nursing expert, 38 years old, shift manager, 13 years of work experience)

Providing both social security and economic security was another important subclass in this sector. The existence of security in working relationships with male colleagues was one of the most important factors which contributed to creating healthy workplaces for women as the study participants reported:

Men joke among themselves. No one indeed has a purpose, for example, men should be aware of the style of jokes they make or the style of their conversation, the words that are used when talking to each other are not used when talking to women, they should be aware of physical contact, this All kinds of things are influential. (Female, 28 years old, radiology expert, 3 years of work experience)

Job security and the feeling of financial independence in women can have a great impact on creating a sense of security that they receive from the workplace. Many participants reported that the existence of discrimination in the allocation of financial resources to women was effective in creating a sense of security and financial independence for women and also the hospital and its management system meeting this part of women's needs can come close to creating a workplace that is effective in women's health:

If I want to say about job security if you are an official, you have more job security, but if you are a company, you can be fired at the beginning of the year, so there is practically no job security. (MS, head of CCU department, 23 years of experience)

4. Providing women's health promotion services

The results of this study indicated that the scope of providing women's health promotion services in the hospital included the hospital occupational health and safety, women's health promotion care, and welfare facilities for women.

Occupational health and safety in hospitals

Paying attention to ergonomics suited for the women’s work environment, providing workplace safety suited for the characteristics of women in the hospital, providing a healthy workplace in hospital conditions, complying with the rules of carrying loads by women, providing equipment suited for the ergonomics of women, and considering many equipment suited for the structure of a male body were the important factors reported by the participants, and also planning for them by managers and officials could contribute to creating a healthy workplace for women in the hospital.

The study participants reported that special attention should be paid to the musculoskeletal system of women because it is different from that of men. Paying attention to musculoskeletal health during pregnancy, the physical pressure caused by patient transportation that women endure in work environments like hospitals could affect their physical health.:

Because we work at the patient's bedside, the physical pressure is higher here. Standing for long periods during visits, giving medicine and moving patients should be taken into account (female, 40 years old, head of the women's ward, 15 years of work experience).

But our environments generally do not respect women's indicators, in the sense that even if the matter is examined from the point of view of ergonomics, it is examined as a total, that is, the ergonomic conditions specific to women are not examined. (MS. member of the board of directors and adviser to the director in family and women's affairs, member of the women's working group in the field of the Ministry of Petroleum)

Ensuring the safety of the work environment by the characteristics of women in the hospital was another factor that contributed to creating a workplace promoting women's health as the participants emphasized. Due to the physical and physiological differences between men and women, it is therefore important to pay attention to them in preventing accidents and ensuring safety:

For example, women are more sensitive to electrocution. In a certain amp, where men don't get electrocuted, women get electrocuted. Because their body resistance is less. It means that they are more communicative than men. Women have more body water and are more affected by electrocution, and this should be taken into account by the system. (Male, PhD. in Occupational Health, Deputy of the Occupational Health Center of the Ministry of Health)

On the one hand, special attention should be paid to the safety of pregnant women, performing repetitive tasks, and standing for long periods which can endanger the health of women in different departments of the hospital, and on the other hand, the health of the fetus and pregnant women working in departments and dealing with dangerous things such as radiology, etc., could engender.:

The hospital must provide the conditions for the mother so that neither the mother nor the baby that is going to be born is harmed, especially in departments such as CT scans or radiology that are in contact with radiation.... (Female, Bachelor of Occupational Health, 27 years old, 3 years of work experience)

Providing a healthy workplace in hospital was one of the most important factors that managers and officials should pay attention to it. Exposure to chemicals and physical exposures, such as light, sound, etc., can have different effects on women due to the physiological and physical differences between them and men. It is therefore important to pay attention to the physical factors contributing to the workplace to meet the needs of working women, ventilation, and control of heating and cooling of the workplace. Paying attention to proper air conditioning and air temperature regulation to create favorable working environments for women who go through different reproductive periods such as menstruation, pregnancy, and menopause were among the important factors reported by the participants; therefore, paying attention to these factors can be of special importance in providing a healthy workplace for women.

The most important thing and we do not have it in this department, is proper ventilation for the health of the space, and the fact that women's body temperature rises during one the month due to hormonal changes, and they tolerate this space without proper ventilation or improper heating system. It's really hard and suffocating. (Lady, 28- years- old assistant, 5 years of work experience)

Women's health-promoting care

The results of this study showed that women's health-promoting care was very important in the workplace, including specializing in women's periodic tests and examinations, developing women's physical activity in the hospital, and paying attention to healthy nutrition and healthy food.

Specializing in women's periodical tests and examinations, focusing on the genitourinary system and the special conditions of women in their different periods of fertility were the important factors affecting women's health the as the study participants reported. Many of the periodical care performed for employees at the workplace are general and the cares were not specific for women:

However, special attention should be paid to women's special issues. For example, in the chest examination, the items related to the breast are not clearly defined. In the examination form, the doctor marks the chest examination and it is easily omitted, and an examination is not performed specifically for women's problems.

Paying attention to a healthy lifestyle in the workplace, such as the development of physical activity for women in the hospital, healthy nutrition and healthy food, etc., is one of factors affecting the health of women in the workplace. The study participants considered the development of women's physical activity in the hospital as one of the important factors which contributed to creating a health-promoting workplace. Special attention should be paid to increasing women's physical activity and creating a supportive environment for women's physical activity at workplaces, such as providing hourly holidays, the existence of compulsions such as financial or time constraints for physical activity, and determining the appropriate time for using the facilities, which were important factors that could have a significant impact on creating a healthy environment for women in the workplace:

I say let's set some hours so that we can exercise. We have morning, evening, and night shifts for our work, clubs should also have morning, evening, and night shifts, for example, until 8:00 PM, and a woman can go to exercise after 8:00 PM. Sports themselves solve many of the children's problems, both mentally and physically, and it affects their health in every way. (Female, 44 years old, head of the neonatal ward, 15 years of work experience)

In addition, many participants pointed out that those hospital policies for proper nutrition could contribute to improving the health of employees, especially women carrying high workload in hospital. Women who spend night shifts and long shifts, pregnant or lactating women, or women who are menstruating, if they do not have healthy nutrition at the right time, in addition to putting their health at risk, can benefit have low fertility and efficiency. In addition, many participants considered not having enough time to eat as one of the biggest problems, which is one of the most important obstacles to having a healthy diet:

In my opinion, nutrition is very important, not much attention is paid to this issue, but it is really important for women, especially those who are breastfeeding, to be able to eat on time and to be given proper food... (MS., 45-year-old office manager, 18 years of the record)

Welfare facilities suitable for women's conditions

Providing childcare facilities and paying attention to the well-being and health of personnel and family are placed in this category. According to the participants, one of the important factors that could contribute to creating a healthy workplace and promoting women's health was the concerns that women had about their children, their care and their place of care:

A child's coach is very important. In the hospital where my sister works, the teacher beats the child. Well, it is very important not to disturb the child. My sister was getting nervous, she couldn't work at all and this made her change the coach. she was so stressed at work; she visited the child every few minutes to ensure that nothing had happened to the child. (Ms., assistant, 28 years old, 3 years of work experience)

The amenities and facilities that the hospital provides to women according to their working time and the provision of facilities inside the hospital to rest during long work shifts can help them maintain a work-life balance and create a calm environment for work. For example, stores that are prepared according to the working time of women working in the hospital can be helpful for them:

It is better if there are stores with hours that match our working hours. We have a store now, but the time is not such that we can use it, I can't go shopping there in the middle of the day, it's great when I'm done with work, I can go shopping for my home. (Female, 38 years old, NICU department manager, 15 years of work experience)

Another thing that exists, in my opinion, is that there is no proper rest room for nursing personnel at all. The worst rooms are usually given for employees to rest (MS., 45 years old, 15 years of work experience)

Providing facilities outside the hospital environment, such as providing sports and recreational facilities outside the hospital environment, can help women stay away from the hustle and bustle of hospital work and according to their life schedule, they can use facilities, such as stores outside the workplace, swimming pool, and use the sports facilities outside the workplace that have been prepared for them with the coordination of the hospital:

Then there is another thing, whether it is a convenience, sports or something, the gym should be indoor, because women don't have time to go outside to do this work, or now they can do it for half an hour, after their work hours or half an hour, in the middle. When they have free time, they can go there and do a group exercise, it will be much better if they can do this, in my opinion. (40-year-old woman, nursing expert, 18 years of work experience)

The findings of this study demonstrated that the support of managers and management systems of medical centers, such as hospitals could be considered as one of the main pillars of creating a work environment promoting women's health. As stated in the second health promotion conference in Adelaide in 1988, women are the first health promoters in the world; based on this, policymakers and organizations should pay more attention to women and support them. In this statement, it is also mentioned that the needs and priorities of women should be taken into consideration in formulating policies and support mechanisms for care activities, such as support for mothers with children, maternity leave, and leave for people under the guardianship of women in the agenda of politicians which should be placed at different levels [16]. Therefore, managers should pay attention to very important but subtle points when examining women's health at work, due to the differences between women and men in terms of various aspects [17].

This study showed that one of the important factors that could have a significant impact on promoting women's health in workplaces was their active participation in the development of programs and policies related to women's health. The presence of women in managerial positions is important for creating a healthy workplace for women, and their cooperation and participation in the formulation of policies and programs related to occupational health and safety can help managers understand the issues and problems faced by women, and also a representative of all groups, especially gender groups, should be present in health and safety related to committees so that a healthy workplace can be prepared for both sexes [14]. Therefore, as discussed in this study, studies also suggest that women's health can be seen in the vision and policy statements of various organizations and workplaces and can help create healthy workplaces. Women care to have a significant impact [9, 18].

Discrimination in having job opportunities and wages of women was another factor that could be considered in human resource management for women. Women are half of the human capital of society and workplaces, which are not only the subject and goal of development, but also an effective factor in advancing development goals [19]. Women are disproportionately socially placed in situations where they are more likely to engage in healthcare work, such as nurses, midwives, and unskilled workers. Men are disproportionately placed in higher jobs, such as doctors and specialists [20]. Also, these discriminations can have an inappropriate effect on creating an environment promoting women's health. Lucero Soledad's study demonstrated that gender discrimination in the workplace can affect women's health. In the study, the perception of gender discrimination was significantly associated with a negative report related to women's health and compared to women who did not perceive this gender discrimination, they reported worse physical health [21, 22]. As found by the study, it is therefore important to pay attention to gender discrimination in the development of human resources and respect the position of women in workplaces like hospitals. Stamarski's study also found that organizational structures, processes, and practices (such as, leadership, structure, strategy, culture, and human resource policy) were interrelated and might contribute to discrimination [23].

Creating the supportive work environments for women, especially those working in environments like hospitals that bring a lot of work pressure and workload for them, can be one of the important policies for organizations and hospital work environments [14]. Working in medical centers can be exhausting. Dealing with patients who have lost their health and morale is very difficult and exhausting and causes anxiety and worry to the staff in medical centers [24]. According to many participants in this study, making the necessary plans by the hospital and managers to moderate women's stress and job burnout and planning to create a balance between women's work and life and create a workplace promoting women's health is very important [25]. Chou et al.'s study reported that long-term exposure to job-related stress led to burnout, which can be defined as a psychological syndrome that may occur when employees are faced with a stressful, demanding workplace. The appearance of high occupation and low resources can endanger their health [26]. However, it should be noted that facing stress in workplaces, especially in hospitals, is unavoidable, and also eliminating stress completely is not possible, but individuals and organizations can learn to manage it.[27] Happiness is one of the main components of mental health, which plays an important role in improving people's health and dealing with stressful situations [28].

In this study, attention has been paid to the design of programs to empower women to deal with stressful work conditions, such as physical activity interventions, meditation, training courses and mental health counseling for women, psychological group meetings, by management systems. The study of Amiri et al. adapts and control the psychological pressures on them and help to reduce them [29, 30]. Seyyed Moharrami's study also showed that holding group therapy training sessions helped the participants to identify stressful situations in the work environment and provide the necessary situations to deal with them [31].

Work and family are two social institutions necessary for individual and social life [32]. As mentioned in this study, paying attention to adjusting the conflict of roles in women and creating a balance between life and work was one of the most important factors, especially for female employees in the treatment sector, such as nurses, doctors, paramedics, etc... Pregnant women, those with infants, and women who struggle with special family conditions are some of the problems reported by the participants and also paying attention to them can help the hospital provide a psychologically healthy workplace for women. Studies showed that conflicts between roles have a greater effect on women. Such conflicts put multiple tasks on the woman's shoulders and raise new issues for her; therefore, if women face problems in establishing a balance between their professional and family roles, they will experience work-family conflict, the consequences of which will not only harm the individual; the organization and at a higher level, the society will not stay away from these problems [33]. Pandey's study found that achieving work-life balance is a problem that can be solved by effective management strategies [34]. Namdari et al.'s study reported that high work-family conflict might have negative consequences, such as job and life dissatisfaction, significant worry, psychological pressure, physical symptoms, depression, job burnout, and marital dissatisfaction, as well as reducing accuracy and quality to follow the provision of services [35]. As stated in this study, Polat et al.'s study also acknowledged that if there was support from the organization and family and gaining experience during working years and training and empowerment, it can be effective in adjusting this issue [36]. One of the factors that can contribute to establishing a work-life balance for women is the support that the workplace and managers can give to female employees in case of family problems, such as having infants or sick children, family and marital problems. In their study, Wong et al. also reported that workplace support in case of family problems could be considered as one of the important factors affecting women’s work-life balance [37]. Similarly, Hui Zhang's study also showed that the effect of role conflict on anxiety can be moderated by social support. Another study revealed that the resources available at the workplace, for example, social support, could neutralize the effect of work-family conflict on anxiety symptoms [38]. Kamrani et al.'s study also showed that training related to the quality of work life and resilience skills and managing stress and burnout could contribute to the quality of work life and creating a work-life balance, which hospital managers shoud pay attention them in order to reduce the effects of this conflict of roles and the pressure caused by them in women [39]. The social environment supporting women's health in the hospital was another dimension identified in this study, which refers to things like solidarity and professional cohesion for women. Pisarski's study demonstrated that a supportive organizational climate was critical for empowering female nurses to cope with shift work and their workplace. In this study, participants perceived a supportive organizational climate as an organizational climate that strengthens collaborative management, the use of positive feedback mechanisms, and job promotion and control over the workplace. This study revealed that providing a supportive environment and adequate resources enables managers and clinical consultants to perform their roles more effectively and support their staff appropriately, which in turn enables them to fulfill their duties. Support and positive interaction between supervisors increase participants' commitment to the department and makes them feel more part of a team, enabling them to work more effectively and feeling well-being and psychological and social health [40]. The safety of women in the hospital is one of the most important factors which can contribute to creating healthy workplaces for them, as the results showed, in order to reduce the amount of violence in the workplace, especially in the hospital, it is necessary for managers to provide opportunities to decrease violence rate in the hospital and reduce the barriers to reporting these cases [41].

Creating healthy work environments for women working in health centers and hospitals is one of the requirements for managers and health systems. Hospitals and medical centers, due to their special conditions, the presence of many clients, workload and long work shifts, and the presence of women as the main forces of health and treatment, have made it important to create a healthy work environment for women. Creating a healthy workplace for women can be considered from different dimensions. The management of the hospital has an executive commitment to women's health and by managing human resources, it creates a healthy mental and social environment for women and, and also their health in physical, psychological, social dimensions can be guaranteed by their participation, and providing health promotion services for women working in the hospital.

WHO: World health organization; MAXQDA: Is a software program designed for computer-assisted qualitative and mixed methods data, text and multimedia analysis in academic, scientific, and business institutions.

Acknowledgements

All participants in this study are appreciated

Authors’ contributions

MF, MM were involved in concept and design of the study. M F did Data collection and data analysis

of studies AF & MMG participated in data analysis. NS, DW contribute in drafting the manuscript.

Final version of the manuscript was approved for all authors.

Funding

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

Availability of data and materials

Data used in this study is analyzed and the data is available from the first author upon reasonable request.

Ethics approval and consent to participate

This study was approved by the Research and Ethics Council of Iran University of Medical Sciences (code: IR.IUMS.REC.1398.201). all methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants prior to taking part in this study. To comply with ethical considerations, before conducting the interviews, the participants were informed about the purpose and necessity of conducting this study, and also the written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Determining the Characteristics of a Healthy Environment Promoting the Health of Women Working in the Hospital: A Qualitative Study

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