CHARACTERISTICS OF THE JOB DEMANDS OF HEALTHCARE WORKERS IN DIFFERENT SEGMENTS OF THE HEALTHCARE SECTOR

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Introduction
Due to the fact that healthcare workers are people engaged in specific activities with the primary goal of preserving and improving people's health may provide direct patient care and service delivery (doctors, nurses, psychologists, social workers, laboratory technicians, etc.) or indirect care (accountants, drivers, administrators, foremen, equipment maintainers, drug distribution, service planners, and even medical waste management) 1 .According to the Law on Health Protection, health care is an activity of public interest, which is carried out in health facilities as a public service that provides health care 2 .Healthcare workers are the key actors in the process of implementation of health care measures and activities in order to provide health services to the patients according to their needs, as well as best medical practice in different health care settings 3 .They have a great responsibility towards human life and health, and at the same time, they are exposed to various psychosocial risks that come from the requirements and conditions of the workplace.These risks include various aspects of work and the work environment, such as the organizational climate or culture, interpersonal relationships, and the design and content of workplace activities 3 .Psychosocial risks at the workplace are related tostress occurrence, burnout syndrome, harassment (mobbing), and violence at the workplace.At the same time, the negative consequences are present not only at an individual level (e.g.psychosomatic disorders in the worker) and at an organizational level (level of work productivity, absenteeism, and presenteeism, increased number of injuries and accidents at work, etc.) but also at the level of social community and national economies (economic losses) 4 .
It is important to note that in the last few years the pressure on medical personnel, especially on doctors, has increased in many countries as a result of various healthcare reforms that affect the autonomy of doctors, imposing more administrative burdens and professional requirements for continuous improvement 5 .
Job demands and job resources are the main elements of the Job Demand-Resources Model (JD-R) [6][7][8] which is used in this research.The central assumptionof the JD-R Model is that whereas every occupation has its own specific job risk factors (characteristics) that affect organizational outcomes, including employee wellbeing, these characteristics can be classified into these two general categories-job demands and job resources.The JD-R model has been proven to have a high predictive value for employee health and wellbeing [6][7][8][9] .
Job demands, actually, refer to various physical (e.g, high levels of noise or crowding), psychological, social (e.g.interpersonal conflicts, abusive supervision) or organizational aspects of the job (e.g.interpersonal conflicts) that require prolonged physical and/or psychological (cognitive and emotional) efforts and therefore they are associated with certain physiological and/or psychological costs in workers.Job demands are not necessarily negative, but high job demands lead to excessive strain when the invested personal efforts are high, which depletes the energy of the worker (emotional exhaustion) and it affects the reduced engagement of the individual at work (energy overload process) [7][8][9] .
On the other hand, job resources as mental, physical, social and organizational aspects of work that provide functionality in the achievement of work goals, reduce job demands and related physical and/ or psychological costs and stimulate personal growth, learning as well asemployee development.Lack of resources at work can lead to changes in behaviour manifested as distancing/negative attitude towards work or cynicism (depersonalization) and disengagement from the work process (motivational process).When the organizational context is presented through adequate work resources, such as proper feedback, supervisor and co-worker support as well as teamwork, high levels of work engagement can be observed among employees, as well as low levels of depersonalization.On the other hand, in the context of reduced job resources (e.g.inadequate feedback, low salary, job insecurity, inadequate supervisory coaching, and poor teamwork), job demands are particularly detrimental [6][7][8][9] .Hence, job satisfaction and good interpersonal relationships can have a protective function against the impact of stress 10 .
Additionally, the problem of psychosocial risks among healthcare workers has worsened as a result of the global public health crisis caused by the COVID-19 pandemic.Research has shown that during the COVID-19 pandemic, stress and burnout syndrome among healthcare workers increased 11 .Lack of health personnel, long working hours without adequate rest periods, and shortages of personal protective equipmentleadto fatigue and non-adherence to infection prevention and control measures. 12Somestudies suggest that infection prevention and control measures reduce the autonomy of healthcare workers and contribute to their exhaustion and occurrence of burnout syndrome 13 .
The aim of this paper is to determine the characteristics of the requirements of the workplace for employees in different segments of the health sector in RNM, categorized into three groups depending on their work tasks in health institutions: healthcare workers in hospital activity, healthcare workers in outpatient activity and employees who are not healthcare workers (technical support and administrative staff).

Material and methods
The paper is a cross-sectional descriptive-analytical study.Employees in health facilities in RNM were surveyed through Google Forms (a cloud-based data management tool used for designing and developing online questionnaires).The survey was conducted during June -October 2022.Participants were asked to complete the questionnaires online and were encouraged to invite new respondents from their contacts.A total of 418 employees in health facilities filled out questionnaires.The respondents were categorized into three groups depending on their work tasks in health institutions: healthcare workers (doctors, specialist doctors, nurses/technicians/laboratory workers) in hospital activity -200 respondents, healthcare professionals (doctors, specialist doctors, nurses/technicians/laboratory technicians) in outpatient activity -166 respondents and employees in the hospital activity and in outpatient activity who are not healthcare professionals, i.e. technical support and administrative staff)-52 respondents.The respondents were informed about the objectives of this research, and their participation was anonymous as well ason a voluntary basis.
In order to determine the demographic characteristics and job characteristics of employees in different segments of the health sector in RNM, specially designed questionnaires were used to obtain relevant data of research interest.
The data on the demographic characteristics, as well as the job characteristics of the respondents, i.e. gender, age, education degree, marital status, profile description of the workplace, type of activity, type of institution where they work,total years of service, length of service at the current workplace, type of employment contract, number of working hours per week, night shift work, work with patients infected with COVID-19, have been obtained from the Questionnaire on demographic characteristics and job characteristics specially designed for the needs of the research through analysis of the literature and the methods used in other similar studies, consisting of 14 questions.
Data on job demands have been obtained with the help of Job Demands Questionnaire specially designed for conducting research through a review and analysis of instruments that have been used in studies in this field 14 , consisting of 28 questions relating to different types of job demands: physical (the fast pace of work, the responsibility for a large number of patients, the lack of personnel, the lack of equipment and materials for work, the burden of administrative activities and additional tasks in the conditions of the COVID-19 pandemic), organizational (the strict hierarchical arrangements of superiors, poor communication between departments, unclear and ambiguous roles and work tasks, frequent changes to rules and regulations in the health facility, the unfair management in the department, the influence of the media on the bad image of healthcare workers from the specific facility and problematic communication among departments in the context of the COVID -19 pandemic), emotional (lack of coopera-tion with colleagues, high competition among colleagues, problems in communication with patients, inadequate handling of negative feelings during work, fear of making a mistake during work and conflict between demands home and work environment, inadequate handling of negative feelings during the CO-VID-19 pandemic) and cognitive job demands (lack of feedback on work results, decision-making under time pressures, insufficient participation in decision-making, obligation to train new employees, as well as decision-making during lack of necessary information and decision-making under time pressures during the COVID-19 pandemic).In doing so, the respondents gave points for each statement according to a Likert scale on which there are five ratings from 1 for "hardly ever" to 5 for "always".The scores given for the statements have been summed and an average value was calculated for the physical, organizational, emotional, and cognitive job demands.
The statistical analysis has been done in statistical programs: STA-TISTICA 12.0; IBM SPSS Statistics 20.0, and the processed data are presented in tabular form.

Results
The average age of all respondents included in the survey is 41 years with a standard deviation of 10.9.Among the respondents, the percentage representation of the female gender is higher at 81.8% compared to the male respondents at 18.2%.Most of the participants in this study have university degrees-120 (28.7%).Most respondents are married or they live with their partner -301 (72%).In terms of job position, i.e. the profile, the most represented healthcare workers are nurses with 45.7%, compared to doctors with 25.4%.According to the type of activity performed by most of the respondents, 200 (47.9%)engaged in hospital activity.A large part of the respondents work at University Clinics 134 (32.1%) and they mostly work in internal medicine (101).The largest percentage of participants in the study are employed with a contract for an indefinite period of time (90%), provide direct patient care (57.9%), and do not work in night shift (69.1%).Most respondents worked with patients infected with COVID-19, i.e. 285 (68.2%).The average value length of total years of service among the respondents is 15.8 years, the average value length of service at the current workplace is 11.2 years, and the average number of working hours among the respondents per week is 41 hours.The difference that is recorded between the three groups of respondents in terms of the average value of the length of serviceat the current workplace is in significant.It is 11.2±8.5referring to technical support and administrative staff, healthcare workers in hospital activity-11.1±9.7 and healthcare workers in outpatient activity -11.3±10.0(table 1).

Q1
The largest number of working hours per week is registered among healthcare workers in hospital activity -41.9±8.9, and the lowest number of working hours per week is observed among respondents who are technical support and administrative staff 39.4±7.0, the difference among the three groups of respondents in terms of the average value of the number of working hours per week is insignificant (table 1).The average values of the answers of all respondents for the statements within the framework of the physical job demands are ordered according to their importance for the respondents: in the first place are the fast pace of work and the burden of administrative activities, then comes the responsibility for a large number of patients and the lack of staff, the additional tasks in the conditions of the COVID-19 pandemic, the lack of supplies necessary for work, the lack of equipment and materials for work (table 5).
As the most significant physical job demands within the group of technical support and administrative staff, the following stand out: the burden of administrative activities, the lack of personnel, and the fast pace of work (table 5).
According to the obtained results, within the group of healthcare work-ers in outpatient activity, the most significant physical job demands stand out the burden of administrative activities, the fast pace of work and the responsibility for a large number of patients (table 5).
As the most significant physical demands within the group of healthcare workers in hospital activity, the following stand out: the responsibility for a large number of patients, the fast pace of work, and the lack of supplies necessary for work (table 5).
The  The average values of the answers of all respondents to the statements within the organizational job demands are ordered according to their significance for the respondents: the influence of the media on the bad image of the healthcare workers from the specific facility, problematic communication among departments in the context of the COVID-19 pandemic, the frequent changes of the rules and regulations in the health facility, the strict hierarchical arrangement of superiors, poor communication among departments, the unclear and ambiguous roles and tasks and unfair management in the department (table 6).
The most significant organizational job demands within the group of technical support and administrative staff stand out: the influence of the media on the bad image of healthcare workers from the specific institution, poor communication among departments, and frequent changes to the rules and regulations in the health institution (table 6).
According to the results obtained within the group of healthcare workers in outpatient activity, the most significant organizational job demands stand out: the influence of the media on the bad image of healthcare workers from the specific institution, problematic communication among departments in the conditions of the COVID-19 pandemic and poor communication among departments (table 6).
The following stand out as the most significant organizational job demands within the group of healthcare workers in hospital activity: influence of the media on the bad image of healthcare workers from the specific facility, problematic communication among departments in the conditions of the CO-VID-19 pandemic, poor communication among departments and the frequent changes of the rules and regulations in the health facility (table 6).
The average value of the difference of the organizational job demands is insignificantly higher among healthcare workers in hospital activity compared to technical support and administrative staffand healthcare workers in outpatient activity.The difference in the organizational demands is significantly higher among healthcare workers in hospital ac- The average values of the responses of all respondents to the statements within the emotional job demands are ordered according to their importance for the respondents: the conflict between demands in the home and work environment, the high competition among colleagues, inadequate handling of negative feelings during the COVID-19 pandemic, the problems in communication with patients, the fear of making a mistake during the work and the lack of cooperation with colleagues.
As the most significant emotional job demands within the group of technical support and administrative staff, the following stand out: the conflict between demands in the home and work environment, the high competition among colleagues, and the fear of making a mistake during the work.
According to the obtained results, within the group of healthcare workers in outpatient activity, the most significant emotional job demands stand out: the conflict between demands in the home and work environment, the high competition among colleagues and the problems in communication with patients.
The most significant emotional job demands within the group of healthcare workers in hospital activity stand out: the conflict between demands in the home and work environment, the high competition among colleagues and the inadequate handling of negative feelings during the COVID-19 pandemic.
The average value of the differences in emotional job demands are insignificant among healthcare workers in hospital activity, technical support and administrative staffand healthcare workers in outpatient activity.The difference is significant in the emotional job demands and it is significantly higher among healthcare workers in hospital activity compared to healthcare workers in outpatient activity in terms ofemotional job demand -problems in communication with patients.
The average values of the responses of all respondents to the statements within the cognitive job demands are ordered according to the importance of the respondents: the obligation to train new employees, decision-making under the time pressures, decision-making under time pressures during the COVID-19 pandemic, the lack of feedback on work results, anddecision-making in the absence of necessary information and insufficient participation in decision-making.
As the most significant cognitive job demands within the group of technical support and administrative staff, the following are highlighted: the obligation to train new employees, making decisions under time pressure and the lack of feedback on work results.
According to the results obtained within the group of healthcare workers in outpatient activity, the most significant cognitive job demands stand out: the obligation to train new employees, decision-making under time pressures during the COVID-19 pandemic, decision-making under the time pressuresand making decisions in the absence of the necessary information.
As the most significant cognitive demands of the workplace within the group of healthcare workers in hospital activity, the following stand out: the obligation to train new employees, decision-making under time pressures during the COVID-19 pandemic, and decision-making under time pressures.
The difference in the average value of the cognitive job demands is insignificant among healthcare workers in hospital activity, technical support and administrative staff,and healthcare workers in outpatient activity.The difference is significant in the cognitive job demands and is significantly higher among healthcare workers in hospital activity compared to technical support and administrative staff about these cognitive demands: obligation to train new employees and make decisions under thetime pressures during the COVID-19 pandemic.

Discussion
The difference among the groups in terms of the following demographic characteristics and job characteristics: gender, marital status, type of employment contract, total yearsof service, length of service at the current workplace, and number of working hours per week is insignificant, i.e. the three groups of respondents on these issues are homogeneous.
Healthcare workers play a central role in health systems, which is certainly confirmed mainlyduring the Covid-19 pandemic, referring tothe lack of health personnel reported as the most common cause of disorders in providing basic health services 15 .Vulnerability in the medical profession stems from psychosocial health problems, organizational requirements, and health care requirements 16,17 .
Employees in the different segments of the health sector are faced with different types of job demands.
The types of job demands and job resources depend on the characteristics of the healthcare institution (e.g.University Clinic, Clinical Hospital, General Hospital, Health Center, etc.) and the job characteristics, i.e. the profile of the worker (e.g. a doctor, a nurse, technical support and administrative staff, etc.).The fact that some worker profiles provide direct patient care and service delivery and are in everyday immediate communication with patients, and others are not, refers to differences in the work process, workplace tasks, work organization, and different disadvantages and risks to which different workers' profiles are exposed 18 .
Employees deal with the following job demands on a daily basis: physical, emotional, organizational, and cognitive.Thus, the results of a study by Mijakoski conducted in two hospitals (University Surgery Clinic and General Hospital) in RNM show the presence of the highest average values for all types of job demand among the surgeons and operating room nurses from both analyzed health institutions 18 .In a similar study conducted to examine differences in burnout, job demands, and teamwork between Macedonian and Croatian hospital nurses, Croatian nurses have reported higher levels of organizational job demands (e.g.strict hierarchy, ambiguous roles, problematic communication) and emotional job demands (e.g.lack of cooperation, high competitiveness among colleagues, emotional involvement in work), while Macedonian nurses have reported higher levels of physical job demands (e.g.excessive workload, time pressure, lack of staff and materials) which is obviously a consequence of their difficult goal -workload (Croatian hospital -250 beds with 250 employed nurses, while the Macedonian hospital -500 beds and 230 employed nurses) 19 .
In this context, the findings of the current study, show that at the level of the entire examined group, the average value of physical job demands (3.The average values of the answers of all respondents for the statements within the framework of the physical job demands are ordered according to their importance for the respondents: in the first place are the fast pace of work and the burden of administrative activities, then comes the responsibility for a large number of patients and the lack of staff, the additional tasks in the conditions of the COVID-19 pandemic, the lack of supplies necessary for work, the lack of equipment and materials for work (table 5).In the three groups of respondents (healthcare workers in hospital activity, healthcare workers in outpatient activity and technical support and administrative staff) as the most significant physical job demand is the fast pace of work, but the groups differ in terms of the exposure to the other physical job demands.The difference registered in the physical job demands in relation to the three groups of respondents is statistically significant for p>0.05.
The average values of the physical job demands in relation to the three groups of respondents are significantly higher among respondents, healthcare workers in hospital activity and healthcare workers in outpatient activity compared to technical support and administrative staff, which means that healthcare workers in hospital activity and healthcare workers in outpatient activity experience the physical job demands more seriously compared to the technical support and administrative staff.This confirms the differences in the characteristics of job demands depending on which segment of the healthcare sector the respondents are involved in.
The average values of the answers of all respondents to the statements within the organizational job demands are ordered according to their significance for the respondents: the influence of the media on the bad image of the healthcare workers ofthe specific facility, problematic communication between departments in the context of the COVID-19 pandemic, the frequent changes of the rules and regulations in the health facility, the strict hierarchical arrangement of superiors, poor communication among departments, the unclear and ambiguous roles and tasks and unfair management in the department (table 6).
In the three groups of respondents (healthcare workers in hospital activity, healthcare workers in outpatient activity and technical support and administrative staff) the most significant organizational job demand is the influence of the media on the bad image of the healthcare workers from the specific facility.The difference registered in the organizational job demands in relation to the three groups of respondents is statistically insignificant for p>0.05.Hence, it follows that the physical job demands should not be neglected, because of the findings similar to those in the current study have also been obtained in other studies.In that context, in research conducted in two hospitals (University Surgery Clinic and General Hospital) in RNM, the physical job demands among respondents of the university surgical clinic are sig-nificantly higher compared to other job demands, and they are also significantly higher compared to the physical job demands among respondents of the general hospital.
Another study, also study conducted in RNM in order to examine differences in burnout, job demands, and teamwork among healthcare workers employed in a general hospital, during two periods oftime (2011 and 2014) showed that the levels of physical jobdemands (increased workload, increased number of patients served and complex administration procedures) were consistently higher compared to the levels of other job demands 20 .
As has been stated previously, high job demands drain workers' mental and physical resources resulting in emotional exhaustion.These job demands affect employee well-being and performance.Various studies confirm the relationship between job demands and reduced productivity 21 and work-related stress, increased medical malpractice 22 as well as mental health disorders in healthcare workers, mainly depression and anxiety [23][24][25] .

Conclusions
The results of this study show that the difference among the examined groups in terms of demographic characteristics and job characteristics are insignificant, that is to say, the three groups of respondents are homogeneous in terms of these issues.
Regarding the most common job demands, the findings show that at the level of the entire examined group, the average value of physical job demands is significantly higher compared to the average values of all other job demands -organizational, emotional, and cognitive.The difference registered in the physical job demands in relation to the three groups of respondents is statistically significant for p>0.05.
These results indicate higher average values of the physical job demands among healthcare workers in hospital activity and healthcare workers in the outpatient activity compared to technical support and administrative staff.
The knowledge that has been obtained about the characteristics of job demands of healthcare workers in different segments of the healthcare sector is the basis for proposing and developing strategies as well as preventive measures at organizational and individual levels.

Table 1 .
Differences among the three groups of respondents in terms of the average values of age, total years of service, years of service at the current workplace, and the number of working hours per week

Table 2 .
Display the demographic characteristics of the respondents in the three groups

Table 3 .
Average values of the key variables in the total sample -job demands

Table 4 .
Differences among the three groups of respondents in terms of job demands

Table 5 .
Presentation of the average values of the physical job demands in relation to the three groups of respondents

Table 6 .
Presentation of the average values of the organizationaljob demands in relation to the three groups of respondents