Prioritizing the Compensation Mechanisms for Nurses Working in Emergency Department of Hospital Using Fuzzy DEMATEL Technique: A Survey from Iran

Aim and Background: Nursing professionals are the most important human resources that provide care in the Emergency Departments at hospitals. Therefore appropriate compensation for the services provided by them is considered as a priority. This study aims to identify and prioritize the factors affecting the compensation for services provided by the EDs nurses. Methods: Twenty four nurses, hospital administrators, local and national health authorities participated in a cross sectional study conducted in 2012. The participants discussed on different compensation mechanisms for nurses’ of EDs, in six groups according to Focus Group Discussion (FGD) technique, resulted in the adopted mechanisms. Opinions of the participants on the mechanisms were obtained via paired matrices using fuzzy logic. Decision Making Trial and Evaluation Laboratory (DEMATEL) technique was used for prioritizing the adopted mechanisms. Findings: Among the compensation mechanisms for nurses of ED services, both Monthly fixed amounts (9.0382) and increasing the number of vacation days (9.0189) had highest importance. The lowest importance was given to the performance-based payment (8.9897). Monthly fixed amounts, increasing the number of vacation days, decreasing the working hours and performance-based payment were recognized as effective factors. Other mechanisms are prioritized as use of the facilities, increase in emergency tariff, job promotions, non-cash payments, continuing education, and persuasive years. Conclusion: According to the results, the nurses working in the EDS of the hospitals were more likely to receive non-cash benefits than cash benefits as compensation.

increase the efficiency of the employees' performance (Kameli, Darabi, Jafari, & Namjo, 2011). Mechanisms of payment have a significant effect on the performance and efficacy of service providers, and satisfaction of the customers. Therefore, one of the major reforms in the health systems are related to the payment mechanisms (Saether, 2004).
One of the occupations that have been considered seriously for compensating the services provided in the health systems is nursing. The nurses as the largest group in hospital play an important role in the success of hospital (Hall, 2002). Providing high quality services and having high productivity require adequate number of trained and skilled nurses. Several studies have noted shortage of nurse as an obstacle for achieving the quality of care (McNeese-Smith, 2001;Aiken, Clarke, & Sloane, 2002;Eastaugh, 2002). Different researches have considered the dissatisfaction of nurses as a cause of workforce shortage (Dehghan Nayeri, Nazari, Salsali, & Ahmadi, 2005;Oulton, 2006;Tschannen & Kalisch, 2009). Dehghan Nayeri et al. (2005) indicated that shortage of nurses may lead to increase mistakes, diminish the quality of care, and enhance patients' dissatisfaction rate.
In Iran, shortage of nurses in hospitals is one of the most important problems. The number of working nurses in Iran is estimated to be one third of the international standard (Sharifi Moghadam, 2010). This condition is a worldwide one, for example as Saether mentioned in many developing countries there is a great nursing shortage. One of the main reasons for shortage of nurses is the impact of wages on the labor supply (Saether, 2004).
There is limited available data at the international level in relation to the compensation for the services provided by the nurses and its changing trend. Most of the countries have studied on how the payroll system can be equitable, and have described the differences among different payroll models. In a study conducted in 2009 by the University of Granada in Spain, the econometric techniques were used to determine the amount of wages paid to health related professions. The findings indicate a significant increase in wages for doctors and nurses, better payments for government staff, and a wage gap in favor of men (Salas-Velasco, 2010). In Organization for Economic Cooperation and Development (OECD) countries, between the 2003 and 2009, compensation in the nursing profession has increased more rapidly as compared to other professions (Buchan & Black, 2011). Studies conducted in Norway, The Great Britain and The United States of America reveal that higher wages can reduce the level of displacement of nurses from this profession. However, some evidences suggest that the costs paid for the displacement are higher than the costs when the nurses are paid more. These evidences are limited, related to some specific countries and are constrained with methodological limitations (Bacon, 2011).
Reports of various countries represent the data related to the compensation of services in three ways: 1) The amount of compensation for all nurses' staff with an average wage is compared among countries. This comparison reveals that people consider the nursing profession as a relatively fetching profession, in terms of financial and social status.
2) The level of compensation in each country is based on the current currency of that country and is calculated on the basis of American dollar. This is used to determine the purchasing power parity (PPP). On this basis, the economic status of the nurses is compared with those in other countries.
3) Average annual growth rate for compensation of services provided by the nursing staff is compared with other staffs that are analyzed during the specific time periods (Bacon, 2011).
Most of the nursing staff is not willing to take the responsibility to work in this department due to the difficulty and stress of the job. The authors' experiences reveal that there is no strong and powerful incentive to encourage and persuade working in the ED S . Furthermore, sometimes working in the ED S is used as a punishment for some nurses, which leads to their break up and displacement from working in this department. Overall, this important department rarely has sufficient, capable and highly motivated staff for providing appropriate diagnostic and vital on time services. In this situation, long waiting time, low quality and incomplete treatment are expectable. The usual strategies that can decrease injustice and the sense of disenchantment in nurses working in ED S are taking the higher rates of compensation, performance-based pay, payment for work difficultness and providing financial support for its implementation (Saether, 2005). In this sense, the present study utilizes the expert opinion to prioritize the compensation mechanisms of the nurses working in ED S of the hospitals in Iran, so that the results obtained can be a valuable evidence for the policy makers and provides appropriate guidance for the executives.

Methods
Twenty four nurses, hospital administrators, local and national health authorities participated in a cross sectional survey conducted in 2012. The participants discussed on different compensation mechanisms for nurses' ED services, in six different groups, comprising homogenous participants, according to FGD technique, as a 1) Heads of nursing offices in Treatment Deputy of the selected medical universities.
2) Administrators of the selected hospitals.
3) Nurses with experience working in ED of hospital from a deprived city of the selected province.
4) Nurses with experience working in ED of hospital with less than 150 beds in the selected provinces. 5) Nurses with experience working in ED of hospital in one of the major referral hospital of the capital of selected provinces.
6) Expert nurses working in National Nursing Council, Iranian Nursing Association, Nursing Office of the Ministry of Health, and Emergency Office.
Data was collected using the questionnaire developed by the researchers. The questionnaire contained 10 factors including: monthly fixed amounts, increase in vacation days, priority in use of the hospital facilities, decrease in working hours, increase in tariffs for ED, job promotions, non-cash payments, higher education grants, persuasive years, and performance-based. Opinions of the participants on the mechanisms were obtained via paired matrices. Weight of factors and interrelationship among factors were determined by DEMATEL technique, using MATLAB software. DEMATEL method, a method for decision making, was originally developed in order to study the complex problematic issues. It has been widely accepted as one of the best tools to solve the cause and effect relationship among the evaluation criteria (Chiu, Chen, Tzeng, & Shyu, 2006;Liou, Tzeng, & Chang, 2007;Tzeng, Chiang, & Li, 2007;Wu & Lee, 2007). This method is applied to derive interrelationship among factors (Lin & Tzeng, 2009). The steps of DEMATEL are as follow:

Preparing of Fuzzy Direct Relations Matrix
Paired comparisons were performed between the main mechanisms and effect of the factor i in a row on factor j in a column was obtained. Fuzzy positive numbers that have been used for these comparisons are shown in Table  1.

Preparing Normalized Matrix of Direct Relations Matrix
In this stage, CFCS method that introduced by Aprikovich and Tsang was used. For normalized direct relations matrix, following relations were used: Triangular fuzzy number was considered as ) , , (

Formation of Overall Relations Matrix
After obtaining the matrix of the combined opinions of the experts (w), by the following equation Matrix X is calculated.
The matrix of the overall relations is calculated by the following equation where I is the mentioned matrix. T X 1 X

Preparing the Diagram of Effector and Effect Relations
Total components of rows and columns of the matrix T were named as D and R vectors, respectively. D represents the sum of the direct and indirect effects of the factor i on others. While R represents the sum of the direct and indirect effects of others. If D+R is large for a particular factor, it shows that this factor has more interactions with other factors. Positive D-R for a factor represents the causal factor and shows that the value i has effects on others, and negative value for D-R reveals that the i is affected by other factors. D and R are also obtained from the following equations: Finally causal diagram through drawn of points with coordinates (D+R, D-R) for each factor is obtained by a Cartesian coordinate system.

Findings
The result of the paired comparisons for importance of the different compensation mechanisms in the view of nurses working in the ED S , is shown in Tables 2 to 5. According to the Table 4 and Figure 1, monthly fixed amounts, increase in vacation days, priority in use of the hospital facilities, decrease in working hours, increase in tariffs for emergency ward, job promotions, non-cash payments, higher education grants, persuasive years, and performance-based payments have the greatest effects, respectively. Negative D-R shows that the monthly    of the perceptions and expectations, negative attitude of the medical team towards their profession, inappropriate clinical working environment, status gap between the doctors and nurses and low wages of nurses were the main reasons for leaving the nursing profession in this research.
One of the issues suggested for the compensation of services is that the cultural and psychological features need to be surveyed. Psychological needs of nurses are suggested in this research. This study has potential implications to nursing policies/practices. Healthcare managers in local and national levels can provide appropriate infrastructure for enhancing nurse's motivation, satisfaction and their productivity. This can be conducted through emphasizing on more important mechanisms of nurse's compensation, diminishing inequity between nursing profession and other professions. The best important strengths in this study are related to interesting topic and data gathering methods. An insufficient literature particularly in national level for comparison current findings with them is a key limitation in this study.