This empirical based survey research is descriptive in nature having quantitative approach. The aim of this research is to understand perception of sanitary workers towards various risk factors associated with heavy workload and its impacts on health, work and behaviour of the sanitary workers working in both private multi-speciality and single speciality hospitals in Tirunelveli city, Tamilnadu, India. In order to achieve these objectives, the study sampled 120 sanitary workers (60 from multi-speciality and 60 from single-speciality hospitals) using convenience sampling technique. Primary data were collected using schedule method and secondary data were collected from books and journals in order to support to the study. The findings of the study reveals that perception of sanitary workers working with both kinds of organization in the study area is same towards risk factors associated with heavy workload and its impact on health and work and behaviour of the sanitary workers.

Keywords: sanitary worker, heavy workload, health, multi-speciality hospital, single-speciality hospital, Tirunelveli city

Background of the study                 

Productivity and employee turnover are the most commonly debatedterms in all kinds of sectors in this current business world as they are directly associated with growth of both employees and organization. Despite many factors, workload which is the amount of work assigned to or expected from a worker in a specified time period remain one of the principal factor deciding both productivity and turnover of the employees. Light workload will evoke laziness and cause employees to involve in group politics and thereby affect their performance and career in their field, at the same time, heavy workload produces health related issues, and dissatisfaction pushing them quit the job. Workload in basically categorised into mental and physical workload, in which, mental workload majorly exist among managerial cadre employees whereas physical workload exist majorly among operating level employees such as sanitary workers. Sanitary workers belonging to non-medical discipline in health care industry, although do not involve directly in patient care activities, play very crucial role such as cleaning urine and faeces of the patients in addition to routine cleaning, mopping of floor, patient room and toilet room which add strong value in prevention of infection and support of daily activities of the patients. Hence, their productivity and retention in the organization for longer period of time remains mandatory for organization since hygienic environment and assistance for the patients are essential in deciding satisfaction and safety of the patients in both multi-speciality and single speciality hospitals. Multi-speciality hospital is a type of hospital where all kinds of specialities such as cardiology, neurology, pulmonology, urology, ophthalmology, orthopaedic, nephrology and all other diagnostic facilities exist under one roof and hence patients can avail all kinds of treatment under one roof. Whereas, single speciality hospital is a type hospital in which particular discipline alone exist and patients can avail treatment for disease related to the particular discipline. In this type of hospital, if patient needs advice for any other conditions which is associated with his or her sickness, they have to go another hospital or wait for consultant who come from other hospital. Role of sanitary workers in both kinds of hospitals is manifold since they need to serve for both inpatients and outpatients continuously. Though they do not need to give much attention to patients in outpatient department, their service is mandatorily needed for inpatients such as patients staying in wards, intensive care unit, and observation ward and operation theatre. They assist giving bathing, cleaning room and washroom, clearing wastages, preparing patients for diagnosis and surgery and transferring them to concerned diagnostic rooms and operation theatre and post-operative wards daily and routinely. The role they have in intensive care unit and operation theatre is manifold since patients need full support from sanitary workers and contribution of sanitary workers is as equal as contribution of nursing employees. Therefore, basically workload remains heavy for sanitary workers and the same workload become double when absence of co-workers and extension of work takes place. Generally in most occasions, higher workload is assigned to the employees with their consent. The employees who accepts this additional workload, is given extra salary in the form of money or leave, but, on the other side, some of the employees are compulsorily given additional workload by extending their working hours and adding additional tasks without adding additional salary. Besides, additional workload is also added by means of assigning personal work of superiors and medical personnel and keeping vacancy positions unfilled for longer period of time.

The study area, Tirunelveli city, capital of Tirunelveli District, located in south end of Tamilnadu, India has attained rich growth in all sectors. Growth in education, cultural changes, technological advancement, population, industrial development has taken place abundantly. Industries, such as bank, textile, transport, hotel, education, insurance, small and medium scale business have grown up largely. Among these growths, health care sector has occupied big place. Government hospitals, private hospitals and clinics, diagnostic centres, blood bank and pharmaceutical centres have increased significantly in numbers. But, still human resource practice in most of the hospitals has not changed and traditional methods of management practice are being followed in most of the hospitals. Lack of professionally qualified managers, two shift work system, twelve hours duty, low salary, lack of attention in career development aspects, absence of proper job description and heavy workload can be seen in almost most of the hospitals. Still, except medical personnel, quality of work life of employees of all other discipline is still below standard and among them quality of work life of sanitary workers is in the position of debatable topic than others. Demand for sanitary workers is increasingly increasing and it remains tough to find new employees for sanitation work and fill vacancy position in current situation. Work culture of hospital sectors, nightshift work, small scale business, education growth and scheme of government such as 100 days employment which is predominant in current scenario are some of the reasons for difficulty to find sanitary workers for sanitation work. As a result, existing employees who are able to stick with culture of hospital sectors for the sake of family and financial situations are assigned heavy workload. When heavy workload is assigned continuously, it will definitely affect their health, work and behaviour. Hence, this research is aiming to investigate and differentiate perception of sanitary workers working in both multi and single speciality hospitals towards various factors associated with heavy workload and how it effectuates their health, work and behaviour.

Need for the study

Infection free and cleanliness environment are the primary factors being expected by patientslargely in this rapidly growing economy and technology based world and they are primarily associated with determining prognosis and safety of patients. Now a day, most of the hospitalsare runas corporate sectors in order to face tough competition among hospitals andfulfildrastic changes that have occurred in taste and preferences of the patients and hence it is quite common to give utmost importance for cleanliness environment for patients by hospital management. Maintaining cleanliness environment in hospital is in the hands of sanitary workers and hence adequate number of sanitary workers and their best performance are important deciding factors to achieve it. Lack of sanitary workers in the hospitals, long absent and poor performance of the sanitary workers will severely worsen cleanliness of the hospital. Among these issues, lack of sanitary workers is purely administrative issue, at the same time, absenteeism and poor performance are both administrative and employees’ issues that have to be rectified by combined effort of both administration and sanitary workers.
For poor performance and absenteeism of sanitary workers, high workload and poor health are the some of the causes among various causes. Many reasons exist for high workload of sanitary workers. Among them, ill-defined job description, bias in assigning workload by manager, poor leadership style of manager, prolonged vacancy, politics among employees, unhealthy work schedule, lack of education and submissive nature of the sanitary workers are some of the common causes.

Virtually, high workload affects health of the employees seriously when it lasts for longer period of time leading to paralysing performance in work since sound health is the primary deciding factor of job performance in the workplace. As cleanliness environment is mainly associated with performance of sanitary workers, when performance and contribution of sanitary workers go down, naturally cleanliness and hygienic aspects of the hospital will be worsening causing high infection rate which will further interfere in recovery of the patients from sickness and reduce not only safety of the patients but also lower satisfaction and reliability of patients and their relatives. Hence, it is the foremost task of hospital management to find out various factors that are associated with workload and how they affect health and job performance of the sanitary workers and how to rectify them in order to improve health and job performance of the sanitary workers.

Scope of the study

Present study has focused sanitary workers working in private multi-speciality hospitals in Tirunelveli city, Tamilnadu. Study discussed health related issues and performance related issues sanitary workers undergo because of heavy workload.

Significance of the study

Results of the present research will be very useful for hospitals and other similar organisations in which sanitary workers are employed to know various factors which increase their workload and how it impacts on work and behaviour of the sanitary workers. Thus present research give knowledge to top level personnel to frame necessary policies or make changes in existing policies such as changes in working hours, work shift and salary and incentives. Middle level managers will get knowledge how to make shift schedules without bias, simplify their work and prepare job description to reduce their workload and increase their work efficiency and commitment. Similarly, for operative level supervisors, this research is helpful to re-examine their leadership style and approach with sanitary workers and treat them accordingly since they are always with them closely. Future research scholars can get deep insight from this research about various gap for their future study.

Objectives of the study

1. To understand and differentiate perception of sanitary workers towards risk factors associated with heavy workload
2. To know and differentiate perception of sanitary workers towards impact of heavy workload on health, work and behaviour
3. To offer suitable suggestions to reduce workload and improve health, work performance and behaviour

Hart & Staveland¹ elucidated workload as the perceived relationship between the amount of mental processing capability or resources and the amount required by the task and Wickens² postulated the main objective of assessing and predicting workload is to achieve evenly distributed, manageable workload and to avoid overload or under-load. World Health Organization 1948 defined, ‘Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity and a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment.³ Erat S et al⁴ analysed how workload impact both individual and organizational stress, their turnover intention and emotional commitment from the sample of 1043 academicians working in state Universities in Turkey. Correlation analysis proved that workload had negative association with emotional commitment whereas it had positive association-ship with stress, responsibility load and turnover intention. Study also observed that though workload had a positive relationship with stress and emotional commitment it had not have any correlation with turnover intention. Akob M⁵ studied how workload, work ethic and job satisfaction influence teachers’ performance and observed that workload determined work behaviour and teacher performance work behaviour and teacher performance. Job satisfaction also significantly influences behaviour of the teachers. Study concluded that workload, work ethics and job satisfaction together made changes in teacher performance of Islamic based school in Makasar. Rahim MS⁶ in their study examined workload under the category of study hours, credit hours and assignment from the students of year 1, year 2 and year 3. Result of study proved that there was negative relationship between study hours and assignments with stress level among second year students. There was positive correlation between credit hours, study hours, assignments with stress level. There was a positive and good relationship between stress level and academic workload which is credit hours among second year students. The study observed that eighty percentages of the students in this study had stress. The highest level of stress was among third year students. However, there was no significant difference at stress level between years of study. The study hours and credit hours differ significantly between years of study. The result assured that when there is increase in credit hours stress level also tends to increase. The study also observed that personal problems and family problems also contributed to stress level among students.

Ali S & Farooqi YA⁷ researched effect of workload on job satisfaction, effect of job satisfaction on employee performance and employee engagement in public sector University of Gujranwab Division and found that work overload had significant negative relationship with job satisfaction and job satisfaction had higher significant positive relationship with employee performance and job satisfaction had also have highly significant positive relationship with employee engagement. Portoghese I⁸ carried out research about burnout and workload among health care workers and proved that workload was significantly associated with higher job exhaustion. Health care workers were more exhausted in response to higher levels of workload when they had low job control.

Elliott DJ⁹ studied association between hospitalist workload and efficiency and quality of inpatient care and proved that hospitalist workload was clinically associated with clinically meaningful increases in length of stay and cost but did not appear to affect mortality or patient satisfaction. Xiaoming Y¹⁰ studied how workload cause burnout and also impact turnover intention of medical staff. The hypothesis tested from 327 medical personnel using factor and multiple regression test identified that workload had significant effect on emotional exhaustion and at the same time workload impacted depersonalisation and also personal accomplishment. Goetz K¹¹ identified the influencing factors on job satisfaction with regard to general practitioners’ characteristics such as age, gender, health behaviour, body mass index and workload. Result of the study proved that majority of the respondents was rather satisfied with their job with exception of hours of work, physical working condition and income. The study also observed that general practitioners working in cities had less working hours per week, less number of patients per day, longer consultation times and a higher proportion of privately insured patients compared to general practitioners working in rural areas. The study also found that being female a higher age, good health behaviour, a lower BMI and a high proportion of privately insured patients were positively associated with job satisfaction.

Qureshi MI¹² in their study conducted with the sample of 250 employees from textile industry in Pakistan analysed what relationship job stress, workload and work environment had with turnover intention and multiple-regression analysis result of the study proved that workload and job stress had positive relationship with turnover intention and also stated that higher the workload and more turnover intention. At the sometime work environment did not have any significant relationship with turnover intention. Hombergh P¹³ analysed how high workload and job stress are associated with lower practice performance in general practice of general practices in the Netherlands. Result found that workload and job stress are associated with practice performance. Result of the study also observed that working more hours as a general practitioner was associated with more positive patient experiences of accessibility and availability. It was also observed that job stress was associated with lower accessibility and availability and insufficient practice management. Higher general practitioner commitment and more satisfaction with the job were associated with more prevention and disease management.

Rajan D¹⁴ examined perception of sanitary workers working in multi-speciality hospitals in Tirunelveli city, Tamilnadu towards impacts of heavy workload on health and identified that long working hours and two shift working system, lack of manpower in the department, long leave of the co-worker and absence of co-worker in department and often extending working hours suddenly were foremost risk factors associated with heavy workload. Tiredness in work place and even after reached home, weight loss, stress and irritation and generalised body pain were foremost impact of heavy workload on health of the sanitary workers. It could be observed from reviewed literatures that various researches have been undertaken as to how heavy workload affect employees and few studies have been undertaken in study area by the researcher, Rajan D^15–18 with regard to how stress and long working hours impact sanitary workers and how workload impacts health. Though few studies had been undertaken about sanitary workers, there is a scope to undertake comparative research about how heavy workload impact health, work and behaviour of the sanitary workers working in both single and multi-speciality hospitals in the study area. Hence, present research is undertaken to fulfil that gap.

This survey based descriptive research has adopted quantitative approach. The element of this research is sanitary worker working in private multi-speciality hospitals in Tirunelveli city. The study has sampled 60 sanitary workers from leading private multi-speciality hospitals using convenience sampling method. Primary data has been collected from them using scheduled method. Questionnaire had been made in English and it was translated to them in Tamil language to collect data from them. Questionnaire had been constructed using Likert’s five point scale which consisted of five responses namely ‘Strongly agree, Agree, No opinion, Disagree and Strongly disagree’ that had been rated with value of 5, 4, 3, 2 and 1 respectively. Questionnaire consisted of three sections, namely section ‘A’ which described demographic characteristics of the respondents, section ‘B’ which revealed risk factors associated with heavy workload, section ‘C’ which talked about impacts of heavy workload on health of the employees and section ‘D’ that indicated impact of heavy workload on work and behaviour of sanitary workers. Secondary data have been collected from journals and books to support study. Percentage analysis, mean and standard deviation were used to analyse data.

It can be understood from Table 1 that among the respondents of multi-speciality hospitals, 26.67% were male and 73.33% were female. Of them, 8.33% were below 30years of age, 31.67% between 30 and 35 years, 33.33% between 35 and 40 years and 16% were above 40 years of age. Furthermore, among them, 96.67% were married and 3.33% were unmarried. In all, 16.67% had below 2 years of work experience, 33.33% between 2 and 4 years, 30% between 4 and 6 years and 20.00% had above 6 years of work experience. Among them, 20% were drawing below Rs. 6000 of salary, 50.00% between Rs. 6000 and 8000, 23.33% between Rs. 8000 and 10000 and 06.67% of them were drawing above Rs. 10000 of salaries. It can be known from Table 1 that among the respondents of single-speciality hospitals, 13.33% were male and 86.67% were female. Of them, 6.67% were below 30years of age, 28.33% between 30 and 35 years, 40% between 35 and 40 years and 25% were above 40 years of age. Furthermore, among them, 93.33% were married and 6.67% were unmarried. In all, 13.33% were below 2 years of work experience, 36.67% between 2 and 4 years, 35% between 4 and 6 years and 15% were above 6 years of work experience. Among them, 15% were drawing below Rs. 6000 of salary, 63.33% between Rs. 6000 and 8000, 20% between Rs. 8000 and 10000 and 1.67% of them were drawing above Rs. 10000 of salaries. It can be understood from Table 2 that risk factors, working hours, manpower, cooperation of co-workers, absence and late arrival of opposite shift duty employees have occupied topmost place, whereas extension of working hours, repair of equipments they handle, job description, seniors and seasonal works have occupied next place in terms of perception of sanitary workers working with both kinds of organization towards risk factors associated with heavy workload. But, sanitary workers working in both kinds of hospitals have shown equal perception towards all factors discussed as risk factors associated with heavy workload. As far as working hours and work shift is concerned, in most of the private hospitals in southern districts of Tamilnadu, rules and regulation of government are not strictly followed. Almost all hospitals adopt system of 12 hours duty with two shift work system.

Late arrival and sudden absence of sanitary workers for duty can commonly and explicitly be seen in most of the private hospitals. The main reasons for these are location of residential place of sanitary workers. Almost all sanitary workers come from village areas and other remote areas which are far away from city and hence they need to travel by two or more buses to reach hospitals and there are limited bus facilities in many village areas. These are some of the reasons why sanitary workers arrive to the duty lately and as most of employees belong to lower income and downtrodden sectors, they cannot afford to taxi or auto or city buses to come to duty in advance or on time. Most of the hospitals do not provide transport allowances separately and they do not give vehicle facilities for sanitary workers and the salary given to sanitary workers are low which is not enough to meet over expenses of their life and hence, they often go to daily wages whenever they get job outside. By means of doing job outside, they are able to earn significant income per day and they can get wages in the same day for the work they do. Because of lack of education, it can be commonly seen quarrel between husband and wife which also make them to avail leave and absence from duty without prior intimation. Since they do physical related work all the time, their health will not cooperate to them to go to job daily and this factor also is one of the reasons why they are availing leave often.

Lack of educationally qualified persons appointed in housekeeping department as managers stand far behind in managing people goodly and encouragingly and they treat employees very biasedly according to caste, religion, income status and personal relationship. This discrimination is also expressed in allocating workload and expressing anger over them verbally. When sanitary workers belong to lower community section, they are allocated heavy workload, at the same time, when they belong to upper community section, they are allocated light workload and given respect in treating them that are absent with lower community section. Despite there is rotation type of shift system, few employees who are very submissive are given prolonged night shift and lack of leadership qualities of managers is one of the reason. When the employee is either married woman or man or unmarried woman, this kind of practice will definitely not only affect their health but also affect their family life very seriously. Shift work remain compulsory for sanitary workers since hospitals provide round a clock service and policy of most of the hospitals states that existing shift workers should leave from duty only after opposite shift sanitary workers arrive to duty. Late arrival of opposite shift staffs will make existing employees leave lately which will further make them reach home lately and thus it will not only increase their stress level but also affect their family life. Moreover, sudden absence of opposite shift staff will make existing employees to extend their shift and usually it happens because of force of supervisors or housekeeping managers. As they had already worked for 12 hours when they are forced to extend duty for 12 more hours continuously without any break, it will undoubtedly affect their health seriously.

Job description is not givento sanitary workers in almost all hospitals. Absence of clear and sound job description pushes sanitary workers to do many works which are not really partof their and it easily creates opportunities to managers or supervisors or other higher officials to compel sanitary workers to carry out household work such as security guard, cleaning toilet, gardening, washing and other assistant works in the house of higher officials. In most of the hospitals, if any assistant cadre employees are absented from duty, naturally they call sanitary workers to do their job. This extends up to buying coffee or tea for higher officials and sending them to shop to buy needed things for them. It can be evidently said that if any employee working with canteen is absented from their duty, simply the next thought comes in mind of canteen manager is to call sanitary worker from housekeeping department to fill that space. Their illiteracy and submissiveness make them to obey to the orders whatever higher officials give and perform those tasks willingly or unwillingly without refuse. These kind of additional workload that are not part of job their job description will unanimously increase their workload weakening their health. Seasonal rush to the hospital is unavoidable in hospital sector, especially during festivals and winter season admission rate in the hospitals would be higher. At this time, workload for the sanitary workers would be heavily assigned from all areas of the hospitals such as medical, paramedical and non-medical areas. In most of the hospitals, all other category of employees such as doctors and nurses would be given additional salary if they treat more patients and do extra work but the same facilities would not go to sanitary workers. Their lack of education and submissiveness limit them not to raise any questions why they are not given any additional monetary income if they do additional work. Another important issue to be discussed is mechanisation in the areas of house-keeping department. Introduction of technology to replace works of sanitary workers and reduce their work burden is almost question mark. Almost most of the hospitals do not take any initiatives in these areas and hence naturally sanitary workers need to carry out their work manually which in turn increase their workload further and affect their health very badly.

Table 3 shows that tiredness in work place even after reaching home, weight loss, generalised body pain and joint pain are the top most impacts of heavy workload on health and they are equally perceived by sanitary workers working in both kinds of hospitals. It can be understood from equal perception of sanitary workers working with both kinds of hospitals that they experience same level of workload. Heavy workload apparently makes sanitary workers tired and pushes them to sleep in work place. Very few hospitals allow sanitary workers to sleep roughly from 30 minutes to 1 hour after lunch as they do physical work, but some hospitals do not show any sympathy towards them and do not allow them to take rest in workplace and they would be continually allocated workload. Continuous work and additional work they perform would cause loss of weight physically. Cleaning latrine and cleaning and wiping faeces of patients of bed ridden in intensive care unit and operation theatre and also in wards are some of the unavoidable work of sanitary workers. When they expose to faeces and urine, they are more susceptible to infection. When weight loss takes place naturally, immunity of the body will reduce which will further worsen health. When sanitary workers continue their work with poor health, their physical health will deteriorate further. This will cause severe tiredness and because of it, after reaching their home, their body condition will push them to go to bed and sleep, but they cannot go to bed because they have to look after their household work such as cooking, cleaning house and other works. As they belong to low income category they cannot have housemaid to look after their household work and if they have any person such as mother or daughter in their house, they would carry out household work and that will assist them to take little rest after reaching house and sleep on time. But, when they do not have any person to assist to their household work, naturally all household works fall on their shoulder and they must do all those works also. When household workload is added additionally with heavy workload that they already did in their work place, naturally their body will get tired and they will sleep very tiredly with severe muscle and joint pain. Therefore, it can be understood that they are in need of health education about safety devices to clean urine and faeces of the patients and how to balance both work and home life, and they also need rest in the work place in the middle of work. Moreover, they have to wake up very earlier in the morning because sanitary workers should go to the hospital work very earlier and they should report to the duty firstly than other department workers because cleaning work should be completed before other department employees as well as patients come to the hospital. Hence, it remains must for them waking up very earlier in the morning in order to get ready for the job. As they start sleeping lately in the night and wake up earlier in the morning, they cannot get up from bed because of body pain, tiredness and sleepiness. Joint pain especially knee, shoulder, hip and back, depression and panic, issues in sleeping and stress and irritation are next highly and equally perceived by sanitary workers working in both kinds of hospitals. This perception also indicates that workload is heavy for sanitary workers in both kinds of hospitals. Basically rules and regulations for sanitary workers are so rigid in all organizations since it is believed that they should be strictly treated in order to get work done from them and that they belong to theory X characteristics. As a result, in many hospitals sanitary workers are not allowed to use lift and hence when they climb steps up and down many times while carrying weights, naturally their joints get suffered and get pain. Under these circumstances, in addition to these kind of physical nature of work, when they are overloaded with heavy work either as a result of absence of co-worker or extension of duty, it will worsen their health further badly.

The reason why sanitary workers undergo depression and panic is that they are mostly either literally educated or uneducated. They do not have literal knowledge about how to bear stress and manage finance and hence they are always on debt side and worried. This leads them to undergo undue stress and depression. Moreover, in lot of workplaces, sanitary workers are not respected appropriately and they are humiliated very pathetically without giving any proper respect for them. Supervisors and managers are very younger in age and they do not have any professional educational qualification and because of these reasons they do not know how to handle sanitary workers and get work from them smoothly and nicely. This is also one of the reasons for their stress and depression in the work place. This undue stress and depression not only affect their health but also collapse their healthy relationship with co-workers and other departmental staffs since they must need to deal with employees of all departments and patients. When they reach home with same stress and depression definitely they will quarrel with husband and children. When same situation persist for longer period of time, it will cause sleeplessness which will subsequently be responsible for causes of diabetes mellitus and hypertension. Most of the sanitary workers who have crossed age of 40 have diabetes mellitus and hypertension which will further cause cardiovascular and neurological disorder if they continuously undergo to heavy workload. When sanitary workers works for longer period of time with too much depression and stress because of heavy work load that persist without any changes in their work pattern and life style, definitely it will make old aged appearance very shortly. Most of the sanitary workers look very old aged because of continuous over workload, depression, worriedness and sickness. Hence, there is a strong need for management to look into long working hours and reduce the workload and changing work shift in order to nurture employees’ health and thereby get productive contribution from them. It can be understood from Table 4 that, work related factors, not able to concentrate in the work and complete work fully, not able to do work assigned by manager, nurse head and patients, not able to assist to the patients, lack of involvement in the work have occupied the top and foremost place, whereas getting absent to work, purposefully avoiding work and carrying out work slowly, postponing work, body pain and getting rid of work wilfully and show lack of involvement in work have been next in line in terms of perception of sanitary workers working in both kinds of organization towards impacts of heavy workload on work. But all factors discussed in health have equally been perceived by sanitary workers working in both kinds of organization.

Among behaviour related factors, not cooperating with other employees and not involving in work that should be done as team, often expressing anger with co-worker and other departmental staffs, often quarrelling with co-workers and shouting other employees in front of patients have occupied topmost place and hiding from people and look for place for resting, not obeying to the superior and disrespecting him or her have been next in line in terms of impact of heavy workload on behaviour of sanitary workers working with both kinds of organization. But all factors discussed in terms of impact on behaviour related factors have equally been perceived by sanitary workers working in both kinds of organization. Concentration in work and complete the work completely remains essential factor for sanitary workers as they are primarily responsible for sanitation of patients and hospital environment. If they do not complete the work fully and if there is any pending work, it will affect hygienic conditions of the patients and hospital environment. As far as patient’s area is concerned, cleaning faeces and urine and preparing patients for surgery by removing hair in concerned places and transferring patients to different places are some of the important work carried out by sanitary workers. All these works need to be performed fully without any deficit, and if there is any deficit the work of cleaning faeces and urine of the patients, it will enhance infection of the patients and thereby worsen condition of the patients. At the same time, if sanitary workers fail to complete work fully in removing hair of the patients for surgery and transfer of the patients, it will endanger patients.

Performing work assigned by manager remains important and when task given by manager is not performed it would not only considered as disobedient, but also it will affect routine work flow of the organization. As far as hospital is concerned, some uncertain and unexpected situation may takes place, for example, a patient may vomit or suddenly a patient may get collapsed. In this situation, manager of housekeeping department would assign work immediately since they need to be done on emergency basis. If the sanitary workers remain with over workload, definitely they may not be able to carry out the task assigned by manager and they would deny it purposefully. The reason behind their denial may be their health condition or dissatisfaction that has taken place because of over workload they had. In this situation, when they do not carry out work assigned by mangers, though it would be considered as insubordination, when viewed from their workload point of view, it can be considered, but it would affect care to be given to the patients, and it may affect patient comfort, and worsen infection rate and also cause dissatisfaction among the patients and their relatives. Getting absent from work and availing leave very often will directly and seriously affect job performance existing employees in duty. In Tamilnadu most of the sanitary workers come from downtrodden and lower income sectors and because of their illiteracy most of them have many children and mostly husband of most of the sanitary workers take alcohol regularly. Household work done in addition to routine hospital work which is excessive, naturally will affect their health very seriously disturbing their deep sleep and it will make them not able to get up from bed. Moreover, social life of the sanitary workers also push them to absent from duty and as they are mostly illiterate they do not know how to plan their social activities and hence they absent to the duty or avail leave without informing in advance. Financial situation and lack of education push them to go to other job which gives them daily wage. Most of the hospitals render salary once in a month, but few hospitals render salary once in fifteen days. Their poor financial education will make them spending their money within few days. As a result, they look for daily wages job to manage daily expenses and most of the sanitary workers want to take all leaves, casual, sick together. These kind of absent and sudden leave will increase dramatically workload of existing employees.

When workload increase very drastically because of absence of co-worker or unfilled manpower in department, they will eventually try to postpone work or try to hide from superior and other employees who basically assign work to sanitary workers. Most of the sanitary workers hide in some places especially in rest room and some other patient’s room which is vacant so that they cannot be called. When they are hidden during crisis situation or peak period, it will virtually affect work flow of the hospital and it will make nursing employees to look after their work such as transferring patients to diagnostic areas and intensive care units. When nursing employees devote time to look after assistance work performed by sanitary workers, it will not only hurdle their nursing work but also endanger safety of the patientsalso. Most of the sanitary workers, when they are forced to carry out duty of employee who have taken leave think that what is the benefit they get as they do additional work of employee who is on leave and when that employee also get salary. Due to this kind of thought, they purposefully do work very slowly and get rid of the work purposefully. This sometimes makes them frustrated and quarrels with other employees. In order to avoid this kind of thought and behaviour from sanitary workers, it is needed that when sanitary department employees perform additional duty which occur due to absent of co-worker, management should give her additional salary. In this way, purposeful withdrawal behaviour of the employees can be avoided. Moreover, when employee workload is increased and they are forced to carry out employees who are on leave or absent they get more frustrated and show angry with all their colleagues and other departmental employees who they are dealing with. As they are uneducated they do not know how to express their anger, difficulties or inabilities which has taken place as a result of too much workload patiently and assertively, instead, they shout commonly in front of patients and other publics in hospital. When this kind of incident commonly takes place in the hospital it will worsen hospital name and dissatisfy patients and get them thinking that this hospital is money oriented and that is why there is no adequate employees in department.

Another important issue being observed in hospitals is that quarrel and misunderstanding between supervisor or manger and sanitary workers. Most of the managers are not educationally qualified and they force sanitary workers to do additional work without considering their willingness and health condition, and in most of the hospitals, in order to satisfy higher officials, managers force sanitary workers to go to their house and do their household works also. Very few sanitary workers accept demand of managers and do additional work and do household works of superiors, some sanitary workers assertively deny it and some sanitary workers burst out when they are forced to do additional work and household works of superiors. Managers of housekeeping department usually want sanitary workers should not raise any questions and should be very submissive and do the work whatever assigned without denying. Some sanitary workers who have literal education and expect equality and wish their self-esteem should be maintained do not accept works which are not part of their job description and not only raise questions but also deny work very boldly. When managers need to deal with that kind of employees, definitely conflict takes place between them and it makes managers speak angrily and harshly sometimes and as a result of this sanitary workers do not concentrate on work purposefully and eventually do not complete work perfectly. This will ultimately not only affect care to be given to the patients but also affect morale of the other employees. Hence, managers should be trained how to handle employees when they are loaded with additional workload and at the same time, management should offer additional incentives when they perform additional work.

Most of the findings in the present study related to impact of heavy workload on health of sanitary workers such as joint pain, sleeping difficulties, diabetes mellitus, hypertension, cardiovascular and respiratory disorder are similar with the study of Rajan D,¹⁷ Rajan D &Vijayalakshmi D,¹⁸ Rajan D¹⁴ who in their studies undertaken with regard to sanitary workers observed that health related issues such as pain in back, neck, waist and shoulder, low energy, difficulty in sleeping and getting up from the bed, weight loss, loss of appetite and irregular sleep, hypertension hair fall and digestive disorder were health related issues of sanitary workers. Present research found that stress is one of the impact occurred because of heavy workload and this finding is consistent with the study of Rajan D^15,16 who in their study found that role related factors which included heavy workload was the reason for stress and it in turn affected individual including health,²⁴ family and social life of sanitary workers. Present research has found that heavy workload is the primary reason for effectuating employees’ life negatively in the form of stress and quarrelling with family members and co-workers.²⁵ These findings go with the study of Gidman WK,¹⁹ Bond C,²⁰ Eden M,²¹ Gidman W,²² who observed that workload increased stress levels among pharmacists and disturbed balancing work and family life. According to present research longer working hours is the risk factor associated with heavy workload and this finding is similar with the study of Bond C²⁰ who found that working longer hours because of demand is the reason for heavy workload. Present research has observed that lack of adequate staff and lack of availability of strong job description are reasons for heavy workload and these findings are consistent with the findings of who indicated that pressure from inadequate breaks and a lack of staff were found as causes of workload among pharmacists and with Shann P & Hassell K²⁵ who investigated that chaotic systems of working, lack of support staff and poor organization.

Suggestions

Following are the suggestions given based on findings of this research:

1. Working hours and shift system should be regulated by reducing 12 hours duty into 8 hours and three shifts into two shift system. Vacancy positions should be filled immediately after an employee quit job since most of the work done by sanitary workers is mainly physically related.
2. Sanitary workers should be oriented in detail about leave and duty timing. They should be instructed if they need to avail leave it should be communicated to their manager in advance so that manager can make necessary arrangement. They should also be instructed that they should be reporting to the duty on time without delay because delay they make will make employee in duty to leave lately.
3. Manager should be advised and trained to plan work shift very perfectly and keep alternatives in order to avoid extending duty shift and working hours since continuous night shift or extension of duty will affect their health status and family life severely. If it is unavoidable to extend their duty and shift work, it should be done with their consent and they can be compensated additionally along with leave or additional compensation whatever they request.
4. Managers should be educated and advised to show equality in offering leave and allocating workload and they should be advised not to show any partiality in terms of junior, senior, caste, religion and other personal relationship. They should also be advised to pay greater attention over senior employee and monitor them if they push their works over junior employees’ or newly joined employees’ shoulder.
5. Clear job description stating what they should do and what they should not do should be given to sanitary workers. It will limit them from doing tasks which are not given in job description and not part of their job. Moreover, management should instruct managers, medical personnel and other higher officials in medical and non-medical departments that they should not assign any personal works to sanitary workers.
6. Sanitary workers should be given significant time and place to rest as they are fully doing physical work. They should be given health education about importance of rest, relaxation, diet and way of managing stress. They should be exclusively given ergonomics training as they are doing majority of the work physically.

Limitations of the study

This study is limited to Tirunelveli city only and it has not covered entire district. Sanitary workers working in private multi-speciality and single speciality hospitals have been focused in this research and nurses working in government hospitals and diagnostic centres or any other organizations have not been focused. Employees working with any other nonmedical departments such as maintenance, housekeeping, canteen and front office have not been studied in this research. Moreover, this present research has not studied how heavy workload affects commitment, job satisfaction and morale of the sanitary workers exclusively. As a result of these limitations, it should be cautious to generalise result of this research into entire district, or other industries or any other occupational groups.

Directions for future research

Future research can be undertaken as comparative study including sanitary workers working in government hospitals and diagnostic centres. Other working class people in hospitals such as nurses, doctors, radiographers, managers, laboratory technicians can be studied that how their health, behaviour, family and social lifeare impacted by heavy workload. Moreover, future research can also be undertaken with same group that how heavy workload exclusively affects job satisfaction, commitment and morale of the employees.

This empirical based descriptive research work has examined and differentiated perception of sanitary workers working in both private multi-speciality and single-speciality hospitals in Tirunelveli city, Tamilnadu, India towards various risk factors associated with heavy workload and its impact on their health, work and behaviour from the samples of 120 sanitary workers (60 from single and 60 from multi-speciality hospitals) who were chosen by convenience sample method. The result of the study revealed that perception of sanitary workers working in both hospitals were equal towards all risk factors analysed in this research and its impact health, work and behaviour also were equal. Result of this study has found that long working hours and two shift working system, lack of manpower in the department, long leave of the co-worker and absence of co-worker in department and often extending working hours suddenly were foremost risk factors associated with heavy workload. Tiredness in work place and even after reached home, weight loss, stress and irritation and generalised body pain were foremost impact of heavy workload on health of the sanitary workers. The study has given suitable suggestions to eliminate risk factors of heavy workload. As most of the work of sanitary workers are primarily physical based, it is a crucial need for hospital management to pay greater attention to eliminate various risk factors associated with heavy workload of the sanitary workers and concentrate on improving their physical and mental health. Hospital management can fulfil these needs by modifying mainly their working hours and work shift and appointing adequate number of sanitary workers according to the workload, giving additional salary according to additional work assigned and providing health education and ergonomic training to maintain their health, get productive work from them and maintain right behaviour in the workplace and thereby get quality service for the patients.

None.

The author declares that there is no conflict of interest.

1. Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): Results of empirical and theoretical research. In: Hancock P, Meshkati N, editors. North-Holland: Human Mental Workload; 1998:139–183.
2. Wickens CD. Processing resources in attention. In: Parasuraman R, Davies R, editors. Varieties of Attention. New York: Academic Press; 1984:63–101.
3. Park K. Preventive and Social Medicine. 16th ed. India: Banarsidas Bhanot Publishers; 2000. 758 p.
4. Erat S, Kitapci H, Comez P. The effect of organizational loads on work stress, emotional commitment and turnover intention. International journal of organizational leadership. 2017;6:221–231.
5. Akob M. Influence workload, work ethic and job satisfaction towards teachers’ performance A study of Islamic based school in Makasar Indonesia. Global advanced research journal of management and business studies. 2016;5(7):172–177.
6. Rahim MSA, Saat NZM, Aishah HS, et al. Relationship between academic workload and stress level among biomedical science students in Kuala Lumpur. Journal of applied science. 2016;16(1):108–112.
7. Ali S, Farooqi YA. Effect of workload on job satisfaction, effect of job satisfaction on employee performance and employee engagement -A case of public sector University of Gujranwab Division). International journal of multi-disciplinary science and engineering. 2014;5(8):23–30.
8. Portoghese I, Galletta M, Coppola RC, et al. Burnout and workload among health care workers: The moderating role of job control. Safety health work. 2014;5(3):152–157.
9. Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Internal medicine. 2014;174(5):786–793.
10. Xiaoming Y, Ma BJ, Chang C, et al. Effects of workload on burnout and turnover intention of medical staff: A study. Journal of Ethno medicine. 2014;8(3):229–237.
11. Goetz K, Musselmann B, Szecsenyi J. The influence of workload and health behaviour on job satisfaction of general practitioners. Family medicine. 2013;45(2):95–101.
12. Qureshi MI, Iftikhar M, Abbas SG, et al. Relationship between job stress, workload, Environment and turnover intentions: What we know, what should we know. World Applied Sciences Journal. 2013;23(6):764–770.
13. Hombergh P, Kunzi B, Elwyn G, et al. High workload and job stress are associated with lower practice performance in general practice: An observational study in 239 general practices in the Netherlands. Health services research. 2009;9(118):1–8.
14. Rajan D. Workload and Health: A study among sanitary workers. College SADANA. 2017;10(1):1701–1709.
15. Rajan D. Occupational Stress among Sanitary Workers. International Journal of Business and Management Tomorrow. 2012;2(9):1–14.
16. Rajan D. Occupational stress among sanitary workers: A comparative study. International journal of applied science and engineering research. 2014;3(1):39–62.
17. Rajan D. Health problems among sanitary workers: A comparative study. JIMS8M: Journal of Indian management and strategy. 2016;21(4):38–43.
18. Rajan D, Vijalakshmi D. Health problems among sanitary workers. College Sadhana – Journal for Bloomers of research. 2016;8(2):1334–1339.
19. Gidman W. Increasing community pharmacy workloads in England: causes and consequences. Int J Clin Pharm. 2011;33(3):512–520.
20. Bond C, Blenkinsopp A, Inch J, et al. The Effect of the New Community Pharmacy Contract on the Community Pharmacy Workforce. London: The Pharmacy Practice Research Trust. 2008. 33 p.
21. Eden M, Schafheutle EI, Hassell K. Workload pressure among recently qualified pharmacists: an exploratory study of intentions to leave the profession. Int J Pharm Pract. 2009;17(3):181–187.
22. Gidman WK, Hassell K, Day J, et al. The impact of increasing workloads and role expansion on female community pharmacists in the United Kingdom. Res Social Adm Pharm. 2007;3(3):285–302.
23. Shann P, Hassell K. Flexible working: understanding the locum pharmacist in Great Britain. Res Social Adm Pharm. 2006;2:388–407.
24. McCann L, Adair CG, Hughes CM. An exploration of work-related stress in Northern Ireland community pharmacy: a qualitative study. Int J Pharm Pract. 2009;17(5):261–267.
25. McCann L. Hughes C, Adair C, et al.Assessing job satisfaction and stress among pharmacists in Northern Ireland. Pharm World Science. 2009;31:188–194.