This survey, an empirical, and quantitative-based descriptive study has been undertaken in Tirunelveli city of Tamil Nadu, India to analyze the perception of managers working in non-medical departments at private multi-speciality hospitals towards five role-related factors ⸺ role ambiguity, role isolation, role overload, self-role distance, and role conflict ⸺ affecting their productivity. To achieve the objective, the study sampled a total of 60 respondents using both purposive and convenience sampling techniques. The questionnaire method was administered to collect the primary data from the sampled respondents, and the secondary data was collected from books and journals. The percentage method applied to analyze the primary data has shown that the majority of the respondents have strongly agreed that all role-related factors, almost equally, affect their productivity, because the difference in the perception level among the discussed variables is very minute as follows: unclear job description about expectations of the hospital as a manager (role ambiguity, 92%); feeling of being isolated from channels of information and not being part of what is happening; not seeing the impact of one’s action (role isolation, 87%); being in-charge for many duties and tasks at the same time which is too much to handle (role overload 87%); finding a conflict between necessities of the job and the personal beliefs and values (self-role distance 83%); and receiving incompatible demand from many heads and various Directions (role conflict78%).

Keywords: manager, non-medical department, role, productivity, private hospital, Tirunelveli city

1. Private hospitals

The number of private hospitals in Tamil Nadu has been increasing dramatically than before, and this is an unprecedented growth sign in the medical field because the number of government hospitals is not sufficient to meet the highly growing healthcare demands of the population. At the same time, there is a huge competition among private hospitals to both attract and retain patients, and all private hospitals are functioning in a corporate style beyond the service intention like other business organizations such as banks, supermarkets, and insurance businesses. As a result of this massive competition, hospitals are investing hugely not only in infrastructure and technology but also on marketing and customer service areas to tackle the competition. Similarly lot of changes have occurred in the culture, attitude, and preferences of the customers: people’s income level has dramatically increased and education level has progressed abundantly. These changes have intensively reflected on business of all kinds: all business entrepreneurs are in the compulsion to change the way they run the business including leadership style and organization culture.  Moreover, patients also ⸺ in light of the changing attitudes and nature ⸺ expect the hospitals to be luxurious like hotels and banks.  They do not want to wait at the hospitals in queue ⸺ considering the pain and agony of the other patient’s ⸺ to avail the treatment, instead everyone especially upper-middle, upper class people and highly educated people want to be treated as immediately as they arrive at the hospitals.   

2. Managers and their importance

Managers ⸺ all categories and levels at the hospitals ⸺ need to work productively to satisfy the growing needs and wants of the patients. Hence, all hospitals, nowadays, recruit managers who are professionally qualified and can work innovatively in order to utilize the resources as fully as possible in all ways and bring abundant profits to the organization in all forms. Moreover, the current situation, the culture of the hospitals has fully changed: the diversified workforce culture has emerged largely and especially the arrival of women in all disciplines at the hospitals is in surge than earlier. To manage them, without any issues, learning all the rules and regulations of the state regarding the diversified workforce is paramount for all managers.  Thus, unlike earlier days, now managers at the hospitals are working under tremendous pressure with deadlines like IT sectors. 

Non-managers’ role is more challenging than all other category managers, because they are in the compulsory position of satisfying everyone: medical, paramedical managers, and the patients. Thus, although they are not directly associated with patient care related works; their role is to give support to all other discipline managers and the patients in all aspects. Compared with medical and paramedical managers, non- medical managers perform multiple roles, which are actually undefined for some departments’ managers.  Since the hospital management think they are just non-medical managers and their role is not as vital as paramedical managers, they are assigned any tasks, which are even the personal works of the higher officials. 

3. Role related factors and their importance

Role defined to managers with regard to what to do and not to do is crucial, because role determines an employee’s work efficiency and effectiveness. Clear role get managers using the resources to the maximum extent, because they know from the role what they ought to do, and not to do, and who they report to and receive order from.  Moreover, when the roles are compatible with their value and dignity, and when managers are shared with information what is happening in the organization, they will not only happy, but also grow their commitment towards the organization and show more involvement to the work, and express proper their respect to the colleagues, seniors and the customers. These are all essential not only to decide their productivity, but also to enhance their retention, which will reduce the employee turnover rate and also reduce recruitment and training costs to the organization. 

4. Productivity

Productivity is concerned with utilization of resources: using less input and achieving higher outcome. Higher outcome is possible only when managers are both efficient and effective in transforming the resources into the better service and product.  Higher productivity of managers brings numerous benefits: high patients’ satisfaction; fewer complaints; better utilization of all resources; less wastage of the resources; better coordination, cooperation, and team work; greater commitment; involvement. Although the vision and culture of the organization play a strong role in deciding the productivity of managers, the leadership qualities, especially a deep knowledge about the subject and field and also experience equally determine the productivity of managers, because they know how to define the role to the subordinates understanding their skills, knowledge, dignity and values.  Lack of vision of the organization, weak work culture, and managers lacking a strong leadership qualities cannot explore the hidden skills of managers and bring out the great outcome from the, and thus they create the environment where managers cannot work productively.

5. Association between role and productivity in the study area

The study area, Tirunelveli city, has achieved a profound growth in the past few years in all sectors. The numbers of health care institutions – hospitals, diagnostic centres, pharmacies; other business sectors such as educational institutions, hotels, transports, banks, fuel stations, tiny businesses, self-help groups and individual businesses through them have increased tremendously. The education level of the people – due to the increased numbers of the educational institutions and peoples’ increased desire to get education and get rid of caste based occupation - has increased significantly and hence, the customer choices and preferences have changed fabulously. All these developments that have taken place in the study area reflect on the hospitals compelling them to provide the best service to the patients in all aspects. Offering the best service and thereby satisfy the patients as completely as possible is in the hands of managers – from top level to low level, from medical to non-medical managers. 

However, in the study area, very few hospitals have engaged managers fully in their work and utilize their knowledge and skills abundantly; many hospitals are underutilizing the potential of managers. Although there are many factors that keep managers engaged and bring their potential out, role-related factors are also equally crucial, however, at many hospitals, in the study area, the role-related factors are substandard – they are neither created nor defined.  Thus, especially managers of non-medical departments - unlike paramedical and medical managers who have the defined roles: patient care activities - are under tremendous pressure, since they are in the compulsory position of doing various roles.  This tremendous pressure gets them not to perform their work with concentration and perfection and thereby they cannot satisfy their internal customers - medical and paramedical managers.  All these effects will result in the following effects: patients’ dissatisfaction - delayed service to them; affect the work of the medical and paramedical managers delaying their work and causing stress to them, because majority portion of their work depends on the work of non-medical departments; employee turnover among managers due to the involvement in numerous duties beyond their capacities and interest.  Thus, since deficiencies in the role-related factors of the non-medical managers not only affect them, but also involve other category managers, it is hugely needed to analyses how far the role-related factors are in practice in the study area for the non-medical managers, and hence this study is undertaken.  

Need for the study

Any objective of the organization – without regard to the type of the organization – can be achieved only with the help of managers, without whom no resource can be converted either into product or service.  Profit attainment – despite all other objectives remain equally important – remains the crucial goal of all organizations to keep them survive and nurture to grow further, which can be attained only by both efficient and effective utilization of all resources.  Productive work of managers by innovative thoughts and ethical ways of work will get other managers (the subordinates) to perform their perfectly.  Lack of productivity of managers not only gets the other resources less utilized, but also leads to wastages of the resources, and the result of which will be un-attainment of the objectives.  Therefore, the supreme duties of all organizations are to keep their managers productive, and if not, other resources cannot be used productively, which eventually will bring massive disadvantages to organizations. 

Although there are many factors – appropriate recognition, fair salary, ethical approach, challenging tasks allocation that assist for their career growth, assigning  sufficient authority, training and development to grow their competency and maximize their retention – deciding the productivity of managers, the role-related factors are equally important in deciding the productivity of managers.  The following role-related factors are paramount to extract productive work from managers: clear job description; not feeling isolated and always having the feeling that the organization value them and treat them as part of it; having allocated with duties and tasks that can be handled smoothly within the capacity; having allocated with work that match one’s personal feelings and values; and having allocated with one reporting officer and receiving work related orders from or through the reporting officer.

The shortcomings in the role-related factors would affect managers’ work and their productivity in the following ways:

1. Role ambiguity gives managers unlimited work that are even boundary-less. When managers continue their work in a prolonged period without knowing what the real works are, their dignity will decline and their workload will increase.
2. When managers feel isolated without knowing what is taking place in the organization and organizations are not sharing that information with managers, their commitment towards the work will get decreased and their morale and attachment to the organization will also get lowered. Similarly, when managers remain in-charge for many tasks, it will increase their workload manifolds and deteriorate their health condition putting the work and family balance at risk. In the same way, when the tasks assigned by organizations do not match their personal values and beliefs, it will create guilty feeling and stimulate the intention of quitting from the job.  Besides, when managers receive information from many heads and from various directions, it will create unnecessary confusion and conflict with other department managers and also with managers who are assigning them job.  Thus, all roles related factors, when they are defect, sub-standard, and inappropriate, they affect the works of managers in all ways.

Since the non-medical managers assist the medical personnel and paramedical managers - who are the internal customers to the paramedical managers - in numerous ways, they must be happy, committed, and perfected in their work to enable their internal customers to perform their work perfectly.  To keep the paramedical managers happy and committed, the hospitals must provide the following: defining their role clearly, sharing the information and keeping them informed, respecting their dignity and values, and strictly following the right channel of communication. However, in the study area, these roles related factors that make managers’ work simple, easy, and energetic are absent.  Managers are performing multiple works without proper job description; they are allocated various tasks, which both hurt their dignity and mismatch with their values; huge discrimination are shown among the middle level managers in such a way that some managers are well informed what is taking place inside the organization and some are not; there is no clear hierarchy system to managers as to who they report to and who they should receive the orders from, and hence they are allocated work from various heads.  Thus, in the study area, managers are doing so much work beyond their working hours.  And, if performing work in these ways continues for prolonged period of time, it will lower their productivity resulting in the following effects: they cannot utilize the resources to be handled by them fully and properly, will express lack of enthusiasm and involvement in their work, and will show imperfection in their work, which will affect their internal customers, in many ways, not to give their best in their work. Consequently, the result of which will reflect on the patients’ satisfaction and organizations’ goodwill.  Hence, it is crucial for hospital management to rectify the defects in the role-related factors and assist the non-medical managers to perform their role as smoothly and efficiently as possible, in order to boost their productivity. 

Study objective

The objective of this study is to analyze the perception of non-medical discipline managers towards various role-related factors affecting their productivity.

Scope of the study

This study has focused on managers of non-medical departments working at private hospitals in Tirunelveli city – the capital of Tirunelveli District - is located at the south end of Tamil Nadu State of India. The study has covered various role-related factors affecting the productivity of the non-medical departments’ managers.

Significance of the study

The study will be useful to the following categories of people. The hospital management can use the findings of this study to make policy related decisions, especially what sort of changes can be made in job description to strengthen it; to give advice to the recruitment department how to choose managers according to the value system of the organization; instruct the concerned managers, who assign duties and responsibilities, to assess the abilities and personal values of managers before assigning the duties and responsibilities; to learn themselves how to remain transparent in terms of sharing the information to all managers without bias. 

In addition, not only managers of non-medical departments, but also other discipline managers can learn, from this study, what various role-related factors are, how they decide their productivity level, and what they have to do to stabilize them themselves when the ambiguous roles are assigned to them and when the information are not shared with them. 

In the same way, this study will give the learning as to how they have to assign role to their subordinates understanding their skills, abilities, and values. Thus, this study assists them to do self-inventory about their strength and weakness and their subordinates also.  Besides, the concept and variables used in this study will serve as the rich source of secondary data for the future research scholars.

A “role” can be defined as a set of norms or expectations applied to the incumbent of a particular position by the role incumbent and the various other role players (role senders) with whom the incumbent must deal to fulfill the obligations of their position.¹ Role ambiguity is defined as individual's uncertainty degree of job expectations.^2-6 Role ambiguity takes place when a person does not know what he/she should exactly do and is confused with formal and informal situations as well.⁷ Role ambiguity disturbs job stability and independence.⁸ Role ambiguity is experienced when the role occupant is not clear about expectations from his/her role.⁹

Role conflict is defined as facing a person with conflicting expectations. These conflicts are usually unreasonable expectations.¹⁰ Role conflict is a negative emotional reactions arising from the demands and inability of managers to complete their work.¹¹ Role conflict occurs when managers do not agree to do certain tasks.¹²

Role Isolation arises when the role occupant feels cut off from the channels of communication. Self-Role Distance is experienced when a role occupant has to do what he/she dislikes, when his/her special knowledge and skills remain unutlilized or when there is a conflict between the image/needs/values of the role and the role occupant.⁹ Role overload- a work condition where people perceive role demands as exceeding their time, energy, and capabilities.¹³ It is experienced by the role occupant when there are too many or too high expectations from his/her role.

¹⁴Found that when higher levels of role conflict and ambiguity exist, there exist lower levels of effort performance and performance reward probabilities.  The results suggested that role conflict and ambiguity are valid constructs in organizational behavior and are usually associated with negatively valued states, e.g., tension, absenteeism, low job satisfaction, low job involvement, low expectancies, and task characteristics with a low motivating potential.

¹⁵examined role overload and underload concerning occupational stress and health and determined if different levels of role demand may be differently associated with job-related stress as well as various health outcomes.  Results also indicated that respondents reporting role overload had the highest level of all negative outcomes – eye, ear, and skin problems, back, head, and stomach ache, muscular pain in arms or legs, respiratory difficulties, stress, overall fatigue, sleeping problems, allergies, heart disease, anxiety, irritability, and other problems, whereas role underload group had the next highest level of outcomes.

¹⁶investigated the effect of role conflict and role ambiguity on managers’ job stress from a sample of 530 managers of Iran’s central Insurance. The result of the study found that role ambiguity affects the work-family conflict; role ambiguity affects the job stress; work-family conflicts affect the job stress; role conflict does not affect the work-family conflict; role conflicts affect the job stress. 

¹⁷investigated the relationships between role conflict, role ambiguity, and proactive behaviors at work (i.e. individual innovation and taking charge) as mediated by work engagement. The study also investigated the moderating role of flexible role orientation on the relationships between role conflict and ambiguity, work engagement, and employee proactivity.  The findings indicated that the conditional indirect relationship between (a) role conflict and taking charge, and (b) role ambiguity and individual innovation through engagement were stronger when the level of flexible role orientation was low.

¹⁸made a study, ‘Factors of Role conflict among working women in the private education sector – a sociological study in Kathua District (J&K)’.  The study found that role conflict was evident in working women in the private education sector.  The study also found that there was more role conflict among married working women than unmarried women because married women are expected to be more responsible than unmarried one.  Moreover, married women need to take care of their children, husbands, and other family members.  Handling children causes more role conflict and distress among them. Besides, the uncooperative nature of the husband or wife is a major factor in role conflict among working women.

¹⁹examined factors influencing role conflict among working women as a sociological analysis with the objectives of ascertaining empirically the nature and extent of role conflict faced by the Indian women working in the organized sector and identifying the major factors and causes owing to which the Indian working women tend to face a situation of role incongruence from the sample of 280 respondents. A majority of the respondents reported that they had high degree of role conflict.  Those who are married, living in rural, SC/ST, OBC, graduation, less income, nuclear family had high role conflict. The result also found that more than one half of the respondents experienced high degree of role conflict whereas another nearly on half of them faced low to moderate level of role conflict.  Working women coming from lower social origin experienced work and family conflict more often due to the socio economic conditions.

²⁰analyzed the effect of role ambiguity, role conflict, external locus of control, and neuroticism on job stress’ from the sample of 120 respondents.  The study tested four hypotheses and the result has proved that role ambiguity, role conflict, locus of control, and neuroticism have a positive relationship with stress, i.e., an increase in the role ambiguity, role conflict, locus of control, and neuroticism variables will increase the stress variables. 

²¹analyzed the effect of multiple role conflicts and work stress on the work performance of female managers.  The result found that 50% of respondents experienced decreased performance; 29.2% did not experience multiple role conflicts; 4.2% did not experience a decrease in performance, 16.7% did not experience multiple role conflicts, 87.2% experienced severe stress, 71.4% moderate and 80.0% mild stress.  The study found that respondents who experienced multiple role conflicts also experienced a decrease in performance.  Those who experienced severe stress also experienced a decrease in performance compared to those who experienced mild stress and experienced a decrease in performance.  There is no effect of work stress on employee performance on managers.  The study concluded that there was an effect of dual role conflict on the performance of female managers, but there was no effect of work stress on employee performance and there was an effect of dual role conflict and work stress on the performance of female managers.

²²in their study, ‘Effects of role overload, work engagement and perceived organizational support on nurses’ job performance during the COVID-19 pandemic’ studied the effect of role overload, work engagement, and perceived organizational support on nurses’ job performance including task performance, interpersonal facilitation, and job dedication.  The result of the study proved that work engagement mediated the relationship between nurses’ workload and task performance, interpersonal facilitation, and job dedication. The study's hypotheses proved that role overload negatively affects work engagement; role overload would negatively affect job performance; role overload is indirectly related to job performance via work engagement. The study concluded that work engagement plays a key role in the relationship between role overload and distal performance outcomes. 

²³examined the role ambiguity and role conflict effect on managers’ emotional exhaustion in healthcare services in Tanzania. The study was carried out in Kaktuke Memorial Hospital in Dar e Salaam, Tanzania from 131 samples.  The study tested two hypotheses and the result found that role conflict does not have a significant impact on emotional exhaustion. The study revealed role ambiguity significantly and positively influences managers’ emotional exhaustion. Secondly, role conflict does not significantly influence healthcare service managers’ emotional exhaustion.

This survey, an empirical-based quantitative study is descriptive, because this study describes the nature of the perception of non-medical managers towards various role-related factors affecting their productivity. The study has sampled a total of sixty respondents (non-medical managers) from the selected leading private multi-speciality hospitals using both purposive and convenience sampling techniques.  From the sampled respondents, the primary data were collected using a structured self-made questionnaire, which consisted of two sections: Section A – entails the demographic respondents of the respondents; Section B – encapsulates perception of the respondents towards the role-related factors affecting productivity.  The questionnaire was constructed based on Likert’s five-point scale with the following five options to be answered by the respondents: strongly agree, Agree, Undecided, Disagree, and Strongly Disagree.  These five options – for the analysis purpose - were provided with values as follows: Strongly Agree – 5; Agree – 4; Undecided – 3; Disagree -2; Strongly Disagree – 1.  The secondary data were collected from books and journals to add appropriate significance to the study. The percentage method has been applied to analyze both demographic details and the perception of the respondents toward role-related factors.

It would be understood from Table 1 that among the respondents 66.67% were male and 33.33% were female.  Of them, 03.33% were below 30 years of age, 30% between 30 and 35 years, 30% between 35 and 40 years and 36.66% were above 40 years of age.

Furthermore, among them, 60% were married and 40% were unmarried.  In all, 15% had below 2 years of work experience, 26.64% between 2 and 4 years, 31.67% between 4 and 6 years and 26.67% had above 6 years of work experience.  Of them, 13.33 were qualified with an MBA degree, 20% with other Master's Degrees, 36.67%, and 20% with pre-college degrees.  Among them, 33.33% were drawing below Rs. 12000 of salary, 43.33% between Rs. 12000 and 16000, 16.67% between Rs. 16000 and 20000 and 6.67% were drawing above Rs. 20000 salaries. 

The analysed data has been interpreted below (Table 2 & Figure 1).  The data collected during the interview process are also incorporated in the interpretation part. 

Figure 1 Perception of respondents towards the role-related factors.

1. Role ambiguity

Clear job description indicating what an employee should do and should not do, what are the goals of the organization and what is expected from him to achieve those goals, how their work must be done – in what order, and in what way their performance and quality of work is assessed is paramount for an employee to perform his duties with great confidence and without fear.  The absence of this information or lack of clarity in the information would plant fear in them and disrupt their self-worth and self-confidence.  Moreover, a sound description statement detailing these details is strongly associated with productivity of managers, because an employee, to engage in his or her duty clearly and deliver great outcome, must know, with crystal clear, what he or she should do and should not do, otherwise, they will be blinking without knowing what they ought to do, and therefore perform multiple works without any perfection and any goal.   

Clear job description is especially important for managers, because they are the vital force deciding how to use the resources – manpower, machineries, materials, and money - of the organization.  Hence, if they do not know clearly what their roles are and how they should exercise their duties and responsibilities, then they would be primarily responsible in the organization for the underutilization of the other resources and lack of productivity and indiscipline of their subordinates.  If managers do not allocate the work to their subordinates and assign the resources and deadlines with detailed instructions, the subordinates cannot be expected to perform well and reveal their full potential. 

In the study area, to know how far role ambiguity affects the productivity of hospital managers, in the questionnaire given to the respondents, most of them strongly agreed that they do not have a clear job description about what they have to do and what the hospital is expecting from them.  When interviewed, the majority of the respondents revealed the same point.  A public relations officer expressed his displeasure: ‘I do not know what my roles are, I am not doing any public relations related work, instead I am doing all personal works of the Doctors; another Finance manager said: ‘In addition to the routine hospital accounts, I am also looking after the Doctors’ personal account; he also continued that although it increases my workload manifolds, I can’t deny that work when Doctors allocated their personal accounts to us.  A security department in-charge said: ‘I have to pay more attention and be alert to protect the vehicles of the Doctors than the clients, and also I have to allocate my department staff to wash and clean the car of the doctors, although these are not my role’.  Similarly, a housekeeping manager said: ‘I have to send sanitary workers from the housekeeping department to the Directors and senior Doctors house to look after their household works – cleaning, guarding, security, and other personal works; She further continued, despite shortage of managers in the department, I have to do these works compulsorily in order to secure the job.  She expressed her regret: ‘I do not know who I have to respond and answer, and I belong to the manager of least important department, I have to obey to the orders of all higher officials without able to deny’. A manager of the cafeteria department regretted: ‘As a canteen manager I am not aware and have not been given any instruction who are my primary clients, who I should give top priority, and in which order I have to perform my duties; for instance, when I was serving to the patients and their attendants, suddenly the assistants of the Doctors or Directors will interfere and place order for food and I have to instruct to my staff to stop what they are doing and serving the Doctors first with top priority.  This, sometimes, dissatisfy my clients.  All these show that I do not know what my responsibility and order of work clearly. These tasks and improper order of work not only increase my workload, but also put my self-work in jeopardy. 

Similarly, a manager of OPD (Out Patient Department) said: I do not know what my daily tasks and goals are, and most of the time I am inactive without engaging with any work most of the time. Although I am a post-graduate and have been given a manager position, most of the time, I am doing the personal works of the Doctors going to the bank and insurance office to look after their personal work, but I do not know clearly what my department works are.  He also continued: since I am not able to engage me with the work, I am not able to use my all skills fully, and I also do not know how to how our performance is assessed by the management and what factor of our work is taken into the account, hence I do not know how effectively and efficiently I have to perform my work.  If there are any guidelines about the criteria and quality factor taken into account to assess our performance, it will be useful for us to concentrate on those factors and complete those tasks with most perfection. 

In the same way, a maintenance manager said: ‘since I have not been given job description, I don’t really know what my roles and responsibilities are; I have been doing the routine work every day without any additional job engagement in my work.  He also continued, most of the time, my subordinate remain ideal without any work, because they have also not been given a job description.  Another maintenance manager said: In addition to doing routine works of my maintenance department, I have been looking after the maintenance work the Director and personal maintenance related works of the Directors such as air-conditioning work or other electrical works in the Directors.  He also continued: since I have not been given job description and I have not known what are the limitations of my roles and responsibilities, I have to do all these additional works assigned by the Directors and other higher officials including Doctors and Surgeons without any monetary benefits.  Although we do not need monetary benefits, we cannot assertively decline that these are not our jobs.  Despite the fact that these are not my works and responsibilities as per my description, since it is the private institution and due to lack of job opportunities, I have to bear all these all work burdens assigned by the Directors. 

A Human Resources Department said: Although I am a HR manager, I have to look after public relation officer work, personal works of the Doctors and sometimes patients’ related works such as meeting the Doctors and requesting them for discharge summary and other nursing managers’ work.  He mentioned, since the hospital has not defined what my roles and responsibilities are, I have to do all these works and I have to report to not only to my Head, but also to all Doctors and Head of Medical Doctors.  Although it is not professional, we have to follow these practices due to unclear job description.  Another HR manager said: being a HR manager, I have worked at the cafeteria as a cashier, because of the fear of job insecurity, and since my job description has not limited me from doing what my duties are.  Another HR manager said: in addition to routine HR works, which even are not clearly defined, I am doing all personal work of the Directors and patients related works also, which are not my works at all.  Since there is no defined policies about the performance appraisal and promotion policy, and there is no many hospitals in these areas and job insecurity, I have to abide by all instruction given by the higher officials and works assigned by higher officials, although these are not professional. 

2. Being in-charge for many duties and tasks at the same time which are too much to handle (Role overload)

Optimal workload is crucial to ensure that managers have sound health, contribute productively, and manage the work and home life in a balanced way.  When he employee has too much workload, it will not only put their health in danger but also lower their productivity, because workload is highly associated with the productivity of managers.  When an employee perform many tasks and remain responsible for many functions at the same time, it will normally increases their workload manifold, which eventually impact on their health, happiness, commitment, and productivity.  Normally, a manager is responsible for everything in an organization both good and bad, so naturally a manager should take more responsibility and workload than other managers to run a department and organization smoothly.  But, at the same time, when the workload is too much to handle, it will be the big burden to him or her, and also it will affect their work in the form of defect in their work, low perfection, poor decision making, unethical behavior and so on. Thus, a manager – to run a department in a smooth and efficient way – must have normal workload to handle.

To the question, ‘being in-charge for many tasks and responsibilities at the same time that is too much to handle, the majority of them recorded their answer: ‘Strongly Agreed”.  In the discussion, most of them said: ‘we are doing so many tasks, and additionally have been appointed in-charge for many works, which are even not related to our area of specialization and our work, all of which cause us too much tired’. One housekeeping manager, discussed, said: in addition to my routine managerial tasks – preparing shift and time schedule, assigning works, monitoring, attending meeting, leading and so many clerical works – I have been appointed by the manager as in-charge for bio-medical waste management.  Although there is a separate bio-medical manager at the hospital, I have been given that responsibility, which in a week consumes a substantial amount of time.  Besides, I have to do inventory check in the canteen once in a week, despite being a separate manager for the Canteen Department.  Moreover, I have to arrange food for Surgeons and other team members, who come from outside hospitals, whenever Open Heart Surgery and Renal transplantation surgery takes place, and look after their needs until they finish their work and leave from the hospital.  Above all, I have been in-charge for the nursing and other managers’ uniform, as part of this, my duty is to go to the textile shop and arrange the tailor and get managers measurement and issuing them uniform after the stitching is over, while maintaining all records about it. She also said: sometimes, I can leave even after 8.00 or 8.30 pm at night having completed all the work.  She expressed her regret that: being a manager for housekeeping department is not easy because I am dealing with highly illiterate people, and the absenteeism is too high and managing the absenteeism by allocating managers to different departments during manpower shortage is a very stressful work, and also getting the work done from them perfectly is the another challenge.  All these works already give us heavy workload and work burden.  Under this situation, when we are additional works which are not part of our department works, the workload even becomes very high.  She also mentioned, since I have not been any job description indicating what my roles of and what are the limitations of those roles, I have to perform all duties being assigned to me. Due to unemployment and low salary in other hospitals, I have to bear all the stress arising from these tasks’.  In the discussion, majority of the housekeeping managers shared the same view about their workload and work responsibilities.

One public relation officer, in the discussion, said: in addition to the public relation work, I have been doing so many other works, most of which are not my public relation related work, such as personal works of the Directors, Doctors and Surgeons; I am heading the Health-checkup Department (He said bringing the patients to the hospitals is one of the duties of public relation officer), which is entirely an additional responsibility; sometimes, the hospital management send me to the court work, which is not completely out of my work field; and also I have been doing bio-medical waste related work also.  All these additional responsibilities increases my workload many folds, which sometimes cause too much stress; work and family life imbalance, because I am not able to leave from the duty on time; create negative attitude towards the work – lower the  job satisfaction and commitment; and sometimes causes the intention of quit from the job. 

Similarly, one front office manager, when interviewed, said: ‘I have to look after all administrative jobs of my front office department – attending phone calls, receiving the patients, answering their queries, collecting the data of the patients who are admitted, and directing the patients who see the doctors as out-patients, allocating the beds for the patients who are referred by the doctors as inpatients, directing the housekeeping managers to prepare the bed, and preparing the shift schedule and monitoring the staff in the department.  All managers in the department are overwhelmed by the too much workload, thus as a manager I can’t leave the department and I have to work as a receptionist always.  In addition to the routine workload, which are too high to handle – due to shortage of managers – I am allocated additional responsibilities by the management.  Most of the time, the additional tasks such as looking after the personal works of the Doctors and Directors increases our workload manifolds. Sometimes, the management shifts managers from the reception to other departments on ad-hoc manner to finish the pending work, during this time as a manager I have to look after the work of the department alone not only as a manager, but also as a receptionist and sanitary worker.  He also continued: as a reception manager I am looking after part of the work of other departments such as insurance, outpatient department, nursing department, laboratory department and medical records department, because reception is the first point to be contacted by the patients, where if the patients are not getting clear details they will neither get satisfied nor wish to take the service from the hospital.  The majority of patients visiting the hospitals wish to have all details from the reception only, so we cannot direct them to the concerned departments.  If we direct them, very few patients agree to go to the department directed to, but many of them will not; instead, they wish to have all details from the reception only.  Thus, as a reception manager, since I have to do all other manager’s work, my workload is too high.  He also blamed the management that his heavy workload arising out of performing multiple tasks is due to absence of job description that limit our works and lack of orientation to all managers in terms of their work and association between the reception and other departments in performing various tasks jointly. 

3. Finding conflict between necessities of the job and the personal beliefs and values (Self role distance)

Matching personal values and beliefs of managers with the organization’s culture and requirement is necessary for managers to enjoy a happy work environment and deliver the productive outcome.  When the personal values of managers contradict with the organization expectation and when managers are forced to do the works against their value system will definitely not only hurt them, lower their efficacy, upbeat, but also grow in them the thought of quit from the organization. 

To the question, whether conflict between necessities of the job and the personal beliefs and values affect their productivity, the majority of managers in the population strongly agreed that it massively affects their productivity.  In discussion, one insurance manager sadly shared some information: ‘I am heading the department where I have to prepare bills for the expenses made by the patients at the hospital for their treatment to reimburse from the insurance companies. In most of the cases, Doctors and top management are forcing us to add some treatment, diagnostic tests, and medicines which actually the patients did not avail from the hospitals, with the intention of quoting a big amount to the insurance companies.  Moreover, the management is forcing us to tell the patients to pay a particular amount in advance before the surgery or diagnosis begin, which as per the insurance rules is wrong – money should not be collected from the patients when they come to the hospital with an insurance card.  After the reimbursement amount come from the company for the patients, who paid money in advance for the patient, the excess amount collected from the patients should be returned to them, but the hospital management hide those information and to cover up that extra amount, we are forced to prepare the duplicate bills for the service not given.  This kind of practice hurt our values, and depresses us, causing us thinking that we are making sins.

Another Finance Manager, when interviewed, expressed his negative feelings about the work he is doing as part of his official work: ‘The management ask me to prepare a duplicate register that has the different salary entry of managers - which actually is not given to managers - to be submitted to the labor office.  Moreover, I am asked to give additional salary to some managers’ in a separate cover without the knowledge of the other managers, and I am restricted from releasing this information to anyone.  Although I am not going to reveal to anyone, this kinds of practice remain unfair, and for being part of this practice, I feel so regretted. He continued, doing work like this remain against my values, which hurts my feelings.  Another manager working at the partnership firm told: one director tells me to give a particular employee additional salary or incentive and hide that matter to another Director, which is definitely not only against ethics, but also against my value.  To cover up this lie, I am compelled myself to tell another lie to other Directors. Thus, I am forced to tell lies, which - when continued - depress me and give me guilty feeling affecting my work psychologically. 

Another HR manager told: I am forced to give pressure to some managers, whom the management decides to send off from the job, by transferring them to another position in other department, which is neither related to their educational qualification, field nor match their skills. If managers are really not suitable to the position or have made the mistakes, which are punishable, it will be acceptable and as a HR manager it is my duty to perform it.  But, against ethics, due to the personal interest of the top officials, when I am forced to give pressure to managers indirectly and get them quit from the job is really painful. Although it is part of the HR manager, when we are supporting to the unethical practice, it hurts me and depress me, which, over the time lower my performance in the work and get me thinking to quit the job. Similarly, in order to give stress to managers, the management use the HR manager.  For instance: once, I was told to give the house keeping uniform to a degree holder working in the non-housekeeping department and force her to wear it with the intention of lowering her dignity and thereby push her to quit from the job. Although it is ethically wrong, being a HR manager, I am obliged to perform the order of my reporting officer. However, when I become part of the unethical work and when it is against my values and beliefs, it stresses me, depresses me lowering my efficacy psychologically, which over the time give me guilty feeling and develop the thought of quiting from the job.

Another OPD manager said: ‘I have been working at this hospital for the past one year, with master degree in Arts, as in-charge for all OPD assistants and also front office managers. In addition to these roles, my role also consists of persuading the patients to get admitted as inpatients as per the direction of the Doctors. More often, the Doctors put the ball on my head; I have to convince the patients to get them admitted as inpatients by giving lot of assurances to the patients.  Although patients do not need to get admitted as inpatients – due to their light illness – I am forced to get them admitted as inpatients because if patients get admitted as inpatients, the concerned doctors who treat them get commission according to the length of the stay in the department as inpatients.  If the patients are uneducated and emotionally weak especially fearful they get admitted as inpatients, which actually is not necessary because treating them as outpatients is more than enough.  Since I play a role of convincing patients to get admitted as inpatients, truly I have to say lot of lies to them, which gives me overwhelming guilty feelings.  However, to safeguard the job, I have to listen to doctors to get patients admitted.  Many times, I have thought why I don’t quit from this job. 

4. Receiving incompatible demand from many heads and from various directions (Role conflict)

To work without confusion an employee must receive orders from one head which is authoritative head.  However, in the current cutthroat competitive business environment, in order that the work should be completed at the earliest and serve the customers as fast as possible with the objective of satisfying them, managers, sometimes, need to receive orders from other managers, who are not in the hierarchy system.  In the interest of fulfilling the needs of the customers, if managers receive instruction from more than one head occasionally, it would be acceptable and manageable, and also, managers would neither take it wrongly nor react to it seriously under the impression of customer satisfaction.  At the same time, on the other hand, if it occurs routinely and repeatedly, it will create unnecessary conflict among managers leading to job dissatisfaction to them. 

With the intention of observing how will when the managerial cadre managers receive instructions from more than one head affect their routine work and thereby affect their productivity causing them mental health disturbance, the question, ‘receiving incompatible demand from many heads and from various Directions’ was asked through questionnaire. To that question, majority of the respondents strongly agreed that they do receive orders and demands from many heads and from various directions, which cannot be done within the time limitation.  When interviewed, one House-Keeping manager said: ‘I am not only receiving the instructions and orders from my authoritative head – the Administrative Officer, but also I receive instructions from other officers – the Directors, their wives, the medical officers (surgeons, consultants, duty medical officers), front office managers, and other department managers – who are not part of my hierarchy officially.  She continued: although my department has the role to be worked with all departments and although it is my duty and responsibility to work with all department heads, when they pass orders authoritatively, it not only hurts me mentally, but also doubles my workload, and sometimes, I find too much difficulty to manage the workload with limited workforce.    She also continued: sometimes, the Directors assign their personal works (for instance, either the directors (chairmen) or their wives from home order me to send housekeeping managers to their house to perform their household works) that I have to compulsorily abide by without any delay and denial, which sometimes cause lack of manpower at the hospital.  Thus, when I perform the order of such higher officials, the routine hospital works get affected in the form of delay and incomplete work, which, sometimes, affect the work of other departments.  When other departmental works are affected, it will cause me tremendous pressure, because I have to answer to my reporting officer.  Thus, I cannot disobey the personal orders of the Directors and at the same time, I have to get the works of all other departments, which are mainly associated with house-keeping department such as all patient care areas – wards, intensive care units, operation theatre, laboratory, catheterization laboratory, and son on – done.  Due to these reasons, most of the days, my department work do not go as per the schedules and it gets me not to relieve from the duty on time, which increases my stress drastically paralyzing my sound sleep and putting my family life in danger. 

To the same question, in the discussion, a Public Relations Officer of a leading hospital said: ‘as a publication relation officer, most of the work I am performing is out of roles given in the job description of PRO role; he also continued: if truly speaking, I am not allowed to carry out my own work, because from different heads – Directors, their wives, medical officers, top administrative officers – I receive orders to perform their personal works such as renewal of their driving license, booking travel tickets, accompanying them to the functions, dealing with their personal issues related to government works, and looking after the works of other managers who are absent or on long leave.  Although many of these works are not directly associated with my work and I do not have sufficient knowledge and skills to perform these works, I cannot directly say ‘NO’ to the top officials when they assign me work.  He continued: in addition, the hospital has not given the appropriate job description, which can limit me from not doing some kinds of works that are not related to my work, I am obliged to do all the works assigned by the top officials.  The important challenge I must mention here is: when I am doing my official PR work, the Directors or their wives or any other senior doctors call me either through phone or through their assistants and assign me their personal work.  At that time, I cannot pay full attention on my PR work, nor can deny the work assigned by top officials.  Thus, without able to manage the situation, I grow anger and stress, the effect of which I show to my family members after I go home.  He also continued, in order to carry out their personal work, I have to roam around the city and travel very far distances through bike, which affect my health also.  To perform their personal work, some doctors do not even give fuel money and I have to use my own money, which increases my expenses also.  Moreover, when some department managers are on leave or absent or when some manager position is vacant, I am asked to look after their work in addition to my routine work. This additional work not only increases my workload hugely, but also put me in the tremendous pressure, because the works of other department managers are not only new to me but also are incompatible to my knowledge, education and skills.  Nevertheless, since it is the private hospital and I cannot deny the orders of the top officials assertively, I have to perform those works compulsorily despite the fact that I do not have any knowledge. Thus, the additional works that I receive from different heads and various directions take my time and energy incredibly putting me in tremendous stress, affecting my health and family life hugely.  

5. Finding that roles and responsibilities are isolated from other managers (Role isolation)

It the common that all managers want to be the part of and are aware of what is happening in organizations, and also want to see what the impacts of their action in organizations are because it not only gives them happiness but also enhances their attachment with organizations. When managers do not know what is happening in organization and not know what impact – both positive and negative – their action has caused to the organization, it will cause the opposite effects: job dissatisfaction, lack of productivity, lack of interest and less commitment towards their work.  Hence, it is paramount that managers should be kept close and get them known what is happening and give them appropriate feedback so they should not feel isolated from the organization.

When the questionnaire was distributed with the question, ‘feeling of not being part of the organization and not being informed of what is happening in the organization and not knowing what is the impact of your contribution to the organization’ most of the respondents have strongly agreed with the underlying truth in the question.  When discussed, one housekeeping manager said: the hospital is not valuing me like how they value other managers such as finance, insurance, and so on, and I am not informed what important thing is going on, but the management keeps some other managers informed. 

Similarly, the top management gives feedback to other managers especially clinical managers about what effect their work has caused to the organization, but being a housekeeping manager I am not given any feedback about the contribution of our department and what kinds of effects – both positive and negative – my department has produced to this hospital. She further added: since managers of the same level in other department receive information and are informed everything what is happening in the organization, and when the same I am not receiving, I mentally feel isolated in this hospital.  She also added: when I feel isolated myself - due to the lack of information from the management - I am not able to pay attention on my work, due to which resources in the department especially manpower are not fully utilized resulting in poor performance of the department. 

Similarly, another Canteen manager, when discussed, said: although I am a middle level manager, I feel that I am not invited for many meetings which the top level management conduct with other middle level managers: HR, Marketing, Finance, and other Para-Medical managers.  In addition, what information the top management shares with and what feedback they give to other middle level managers are not shared with me. Similarly, how my canteen department works and how those works play a role in satisfying the patients and other managers in the hospitals is also not shared with me.  Canteen department play a crucial role in fulfilling the needs of both patients and other stakeholders arriving at the hospital.  My department managers do all their work in standing position under the heated environment, but when they are not given feedback (if they are given feedback, it would give definitely a good vibration and motivation leading them work more committed), definitely, they will feel depression, lessen their commitment leading them to perform ineffectively. Thus, when as a middle level manager, when I am not given equivalent value and respect what other middle level managers are given and am not shared with information that are shared with other middle level managers, I completely feel isolated and feel that my role and position are not as important as other middle level managers. This kind of feeling get me depressed lacking my attention to the work causing less productive. 

Similarly, another security manager, when discussed, revealed the same concern what other two managers did.  He added: I am qualified with a master degree, and have been assigned to the security department as a manager to handle this department.  However despite the professional qualification, I am seen and treated differently from other department managers, who are dealing with primary functional departments, by top management. I am not given due importance, because I am serving in the security department, which is seen lowly by the management.  In addition, I am not shared most of the information which are essential and shared with other managers, and due to which I feel isolated from the hospital. Thus, this feeling of isolation slows my work speed, minimizes my ability of getting work done with my subordinates, which haphazard the work of the security department.  Due to this isolation, I feel that I am not given due recognition, which reduces my skills to effectively utilize the resources of the department, sometimes I have felt of quitting from the job.

Based on the analysis of the findings, the following recommendations are given.

1. Clear job description stating what managers ought to do, not to do should be given along with the detailed orientation to limit managers from doing non-managerial works.
2. Transparency should be maintained throughout the organization, especially through appropriate communication channels. Besides, all managers should be informed about what is happening at the top management level without considering any manager as inferior or not important.
3. Whenever allocated the tasks to managers, their dignity and personal values should be considered and respected; and, whenever the tasks to be allocated seem to hurt the values of managers, they should be avoided in order to decline the employee turnover of managers.
4. The hierarchy level of the management - who managers should report to and the order should be taken from should be established and maintained firmly throughout the organization to get managers not to receive tasks from other heads who are not authoritatively supposed to give orders.  

Limitations of the study

The study has the following limitations:

1. The first limitation of the study is the study area: The study is limited to Tirunelveli city, and it has not covered the entire District.
2. The second limitation is the study population: It has focused on non-medical department managers working at private-multi speciality hospitals. The study has neither covered paramedical managers nor medical managers nor any other category managers nor focused on single speciality hospitals, government hospitals, and diagnostic centres. 
3. The third limitation of this study is sample and sampling technique: The study has sampled sixty respondents and used non-probability sampling techniques ⸺ convenience and purposive.  Similarly, the study has used a basic tool ⸺ percentage analysis, and hypotheses have not been formulated and analyzed.
4. The fourth limitation of this study is the variables used in this study: The study has analysed only role-related factors, and has not analysed other variables ­­­­­⸺ organization policy and management practices, professionalism, salary and welfare facilities and so on ⸺ that influence the productivity.  Similarly, in this study how role-related factors influence other variables: organizational commitment, morale, job satisfaction, and motivation.

Future research direction

This study will serve as a strong base and open gate for research scholars to carry out various research related to this topic and similar topics in the future.  In particular, this present study serves in the following ways for future research studies:

1. The same study can be extended to the whole District and other Districts with large samples using a probability sampling technique.
2. Managers working in other paramedical and medical departments can be studied under the same topic. In the same way, non-medical managers working in single speciality hospitals, government hospitals, and diagnostic centres can be focused. 
3. Attempts can be made ⸺ as a comparative study ⸺ to know how the impact of role-related factors affecting productivity differ among managers of other disciplines such as para-medical managers and medical managers. Also, other occupational groups besides managers such as receptionists, radiographers, accountants, sanitary workers and so on working at the hospitals can be studied to understand how their roles affect their productivity.
4. In the same way, studies can be undertaken to examine how role-related factors impact organizational commitment, morale, job satisfaction, and health of the same non-medical managers' group, or any other occupational group.

Conclusion

This survey, an empirical, quantitative-based descriptive study undertaken in Tirunelveli city of Tamil Nadu, India had the objective of analyzing the perception of managers working in non-medical departments at private multi-speciality hospitals towards five role-related factors ⸺ role ambiguity, role isolation, role overload, self-role distance, and role conflict ⸺ affecting their productivity.  To achieve the objective, the study sampled a total of 60 respondents using both purposive and convenience sampling techniques.  The questionnaire method was administered to collect the primary data from the sampled respondents, and the secondary data were collected from books and journals. The percentage method applied to analyze the primary data indicated that the majority of the respondents strongly agreed that all role-related factors, almost equally, have affected their productivity because the difference in the perception level among the discussed variables is very minute as follows: unclear job description about expectations of the hospital as a manager (role ambiguity, 92%); feeling of being isolated from channels of information and not being part of what is happening; not seeing the impact of one’s action (role isolation, 87%); being in-charge for many duties and tasks at the same time which are too much to handle (role overload 87%); finding conflict between necessities of the job and the personal beliefs and values (self-role distance 83%); and receiving incompatible demand from many heads and various Directions (role conflict78%).  Since non-medical discipline managers play a supreme role in assisting medical personnel to offer timely service for patients, they need to be provided with clear job descriptions and detailed information about what is going on in the organization, be assigned the work that matches their values, and beliefs, be given order from one head instead of many heads so that they can work productively and stress-free. Therefore, hospitals should focus on these role-related factors that paralyze their work and contribution and fix the discrepancies if there are any to enable them to deliver their duties productively.

Data generated or analysed during this study are available from the authors upon request.

The authors declare no conflict of interest.

1. Banton M. Roles: An Introduction to the Study of Social Relations. New York, NY: Basic Books, Inc; 1965.
2. Baral R, Bhargava S. Work-family enrichment as a mediator between organizational interventions for work-life balance and job outcomes. J Manag Psychol. 2010;25(3):274–300.
3. Epie C. Managing time-based conflict across life domains in Nigeria: A decision-making perspective. Ife Psychologia. 2009;17:194–216.
4. Fayankinnu EA, Alo OA. Globalization and work: An insight from the Ghanaian and Nigerian women experience. Gender Behav. 2007;5(1):1129–1161.
5. Akanji B. Realities of work-life balance in Nigeria: Perceptions of role conflict and coping beliefs. Bus Manag Educ. 2013;10(2):248–263.
6. Verbeke W, Dietz B, Verwaal E. Drivers of sales performance: a contemporary meta-analysis. Have salespeople become knowledge brokers? J Acad Mark Sci. 2011;39(3):407–428.
7. Schulz J, Auld C. Perceptions of role ambiguity by chairpersons and executive. Sport Manage Rev. 2006;9(2):183–201.
8. Wall T, Cordery JL, Clegg C. Empowerment, performance and operational uncertainty: A theoretical integration. Appl Psychol Int Rev. 2002;51:146–149.
9. Pareek U. Making Organizational Roles Effective. New Delhi, India: Tata McGraw-Hill Publishing Company Ltd; 1993.
10. Wallace JE. Job stress, depression and work-to-family conflict: A test of the strain and buffer hypotheses. Relat Ind/Ind Relat. 2005;60(3):510–539.
11. Safaria T, Othman AB, Wahab MN. Role ambiguity, role conflict, the role of job insecurity as mediator toward job stress among Malay academic staff: A SEM analysis. Curr Res J Soc Sci. 2011;229–235.
12. Yongkang Z, Weixi Z, Yalin H, et al. The relationship among role conflict, role ambiguity, role overload and job stress of Chinese middle-level cadres. Chin Stud. 2014;8–11.
13. Rizzo JR, House RJ, Lirtzman SI. Role conflict and ambiguity in complex organizations. Adm Sci Q. 1970;15:150–163.
14. Schelur RS, Aldag RJ, Brief AP. Role conflict and ambiguity: A scale analysis. Organ Behav Hum Perform. 1977;20:111–128.
15. Shultz KS, Wang MO, Olson A. Role overload and underload in relation to occupational stress and health. Stress Health. 2010;26:99–111.
16. Soltani I, Hajatpour S, Khorram J, et al. Investigating the effect of role conflict and role ambiguity on employees’ job stress: articulating the role of work-family conflict. Manag Sci Lett. 2013;3:1927–1936.
17. Maden-Eyiusta C. Role conflict, role ambiguity, and proactive behaviors: does flexible role orientation moderate the mediating impact of engagement? Int J Hum Resour Manag. 2017;32(13):1–16.
18. Bhandari RK. Factors of role conflict among working women in the private education sector – a sociological study in Kathua District (J&K). Int Res J Comm Arts Sci. 2018;9(4):123–128.
19. Somashankar C. Factors influencing role conflict among working women—a sociological analysis. IOSR J Hum Soc Sci. 2018;1(10):35–41.
20. Wibowo PSH, Purnomo R. The effect of role ambiguity, role conflict, external locus of control, and neuroticism on job stress. J Res Manag. 2019;2(3):12–21.
21. Muis M, Naiem MF, Arsin AA, et al. The effect of multiple role conflicts and work stress on the work performance of female employees. Gac Sanit. 2021;35(S1):S90–S93.
22. Zhang NA, Xu D, Li J,et al. Effects of role overload, work engagement, and perceived organizational support on nurses’ job performance during the COVID-19 pandemic. J Nurs Manag. 2022;30:901–912.
23. Mwakyusa JR, Willey E. Role ambiguity and role conflict effects on employees’ emotional exhaustion in the healthcare services in Tanzania. Cogent Bus Manag. 2024;11(1):1–12.