Factors Affecting Productivity of Managers: An Empirical-based Comparative Study

The aim of this empirical, quantitative and survey-based descriptive research undertaken in Tirunelveli city, Tamilnadu is to understand and differentiate perception of the managers working in non-medical and paramedical departments in private multi-specialty hospitals towards various factors affecting their productivity. The study has analyzed eleven main variables namely organization structure and policy, role, superior and leadership, resource and communication, managerial practice and skill, professionalism, career development, facilities, subordinates and patients, coordination and cooperation and work-home conflict to understand their perception. The study has sampled 80 managers (40 from paramedical and 40 from nonmedical categories) using purposive sampling technique. Primary data have been collected using structured self-made questionnaire. Secondary data have been collected from books, journals, thesis, projects and conference proceedings. Percentage, mean, standard deviation and coefficient of variation have been administered to analyze the data. The results of the comparative study indicate that the factors, organization structure and policy, superior and leadership, managerial practice and skill, career development, coordination, and cooperation and work-home conflict have been equally perceived by managers of both categories. Role, professionalism and facilities related factor have been highly perceived by managers of the nonmedical category. The factor subordinates and patients have been highly perceived by a paramedical manager with little variation. The study has offered suitable suggestions to improve the productivity of the managers of both categories.


Background of the study
Healthcare has become one of India's largest sector creating both revenue and employment. Healthcare sector includes hospitals, diagnostic centres, clinics, health insurance, and medical equipment. Among these, hospitals play a major role in deciding operations of other sectors in healthcare. Hospital sector consists of two major kinds namely government and private that include multi-specialty and single specialty category. In all these kinds, three main disciplines namely medical, paramedical and nonmedical exist. Medical discipline comprises medical consultants, registered medical officers and surgeons. Paramedical discipline comprises nursing, pharmacy, medical records, laboratory, and radiography. Both medical and paramedical disciplines directly deal with patients and involvement in patient care activities. The nonmedical division consists of human resources, finance, material, public relation, housekeeping, maintenance, insurance and corporate, front office, security, and canteen or cafeteria departments. All these departments provide supportive services for the paramedical and medical disciplines. Among them, few departments such as insurance and corporate, cafeteria and front office have direct contacts with the patients. Despite there are direct contacts, they do not involve in patient care activities. All these three divisions are interconnected and without the support and contribution of one discipline, another discipline cannot perform and complete their duties. Thus, coordinated efforts and teamwork of all these three disciplines and productive contributions of each manager in all disciplines are crucially needed for the growth of the hospitals Expanded globalization, increased technological advancement, significant socio-cultural changes, and rich economical changes have brought dramatic changes among all sectors of people namely lower, middle and higher income people towards the healthcare industry. The same kind of changes that have taken place among the people about restaurants, banks, and insurance, telecommunication and transport sectors has also taken place about hospital sectors also. People expect the same kinds of approaches and operations what they receive from those commercial sectors expect from hospitals also. This sort of changes occurred in customers' mind have compelled hospital sectors to run their organization like other commercial business sectors. The result is that all private hospitals started running their organization as a star hotel paying a plethora of attention towards satisfaction of the patients.
Since lot of corporate sectors which are not related to the health sector has begun to start hospitals, competition among hospitals also has increased tremendously unlike olden days because in earlier days usually doctors were running hospitals. Every hospital began introducing attractive scheme like what textile, education, hotel, and insurance companies do to attract the patients. Health care marketing has become one of the necessarily important functions not only in hospitals but also in all other health care sectors such as pharmaceutical and diagnostic sectors. Thus, as the movement of the hospitals has changed a lot because of changes that have taken place in patients' mind, increased competition and corporate type operations, all hospitals are in the compulsory position to recruit professional managers.
Roles of the managers are highly and mandatorily needed now a day to the hospitals in order to tackle increased competition, customer preferences, and changes, technological advancement and changing laws of the country related to the hospitals and therefore run the hospitals successfully by satisfying patients, increasing profit and maintaining the reputation of the hospitals. Unlike olden days, in the present days, managers working with hospitals which is run by doctors have been given lot of freedom in many hospitals to take decision individually, introduce innovations, undertake advanced research and take risk because in hospitals run by hospitals doctors spare lot of the time in patient care activities such as diagnosis and surgeries and hence they cannot devote their time to look after administrative activities. But, at the same time, in hospitals which are run by corporate sectors, a team of strong administrators looks after administrative work and they decide including the appointment of doctors, thus, in both types of hospitals role of managers are inevitable.
In this fast growing technology-based world, it is essentially needed to study about way of recruitment, training, motivation, career development opportunities and professionalism shown towards the hospital managers and how they are reflecting on managers of both paramedical and nonmedical categories working in multi-specialty hospitals in the study area, Tirunelveli city which is the kind of second tier city in Tamilnadu, India. The study area has reached outstanding growth in the areas of health care sectors. Many multi-specialty, single specialty hospitals, clinics, diagnostic centres, pharmacies have emerged newly in large number in the past few years because of increasing population growth, education development, and socio-cultural changes. Despite there is rich growth in health care aspects, human resource management practice and professional way of handling managers and professional way of performing administration remain lack and substandard in almost all hospitals. Although many hospitals in developed cities like Chennai, Madurai, and Coimbatore have started to recruit professionally qualified managers to look after their administration work, still that kind of practice is not followed in Tirunelveli city. Managers for nonmedical divisions are appointed not based on educational qualification and value system and they are purely appointed on caste, religion, and recommendations. Although managers for paramedical divisions are appointed based on educational qualification, the same caste and religion aspects are still prevalent in their appointment.
In the study area, few managers retain in the organization for a longer period of time because of family situations and financial commitment. Most of the professionally and educationally qualified managers do not retain in the hospitals for a longer period of time and they quit the job very shortly because of lower salary, lack of professional approach by higher officials, lack of scope for career development, bias in promotion and increment and improper job description. In order to get productive work, managers are needed to be treated professionally with proper salary and adequate manpower and other resources in the department, proper job description, training and development and so on. Unless these factors exist strongly, on the one side, it will affect their production level and deteriorate their career growth, on the other side, it will cause a negative impact on the reputation of the organization and dissatisfaction of the patients because of the results of lack of productivity of the managers. Thus, it is needed for the hospital management to identify the factors that deteriorate their productivity of the managers of both paramedical and nonmedical categories and rectify those factors in order to enhance their productivity and thereby maximize the satisfaction of the patients, deliver safety service for the patients and grow the reputation of the hospitals. In view of these reasons, this present research has been undertaken in the study are to identify and differentiate various factors affecting the productivity of both paramedical and nonmedical managers working in private multi-specialty hospitals.

Statement of the problem
Continuously ensuring productivity of both paramedical and nonmedical managers remain crucial activity since they play a major role in diagnosis, prognosis, satisfaction of patients and reputation of the hospital by supporting strongly to the medical personnel. Though managers carry out various works, the main objective existing behind these all work is to utilize the resources to the maximum extent. In order to utilize resources fully, managers need abundant knowledge as to how to get the work from their subordinates fully. To achieve it, they need strong managerial skills, clear cut roles, professional respect, enough resources in terms of manpower, machinery and technology, knowledge of how to balance both family and home life, supportive leadership style of the superior, cooperation and coordination from superiors, subordinates and colleagues, adequate pay and fairness in promotion and transfer and enough facilities. Presence of all these factors will definitely give the manager enough enthusiasm and dedication to contribute to maximize the satisfaction of both the patients and the employees and also grow the reputation of the organization. Lack or absence of these factors will bring the opposite effect because they will not give a platform for the managers to exhibit their skills and knowledge wholly, satisfy patients and employees, and contribute to the growth of the organization.
In the study area, employee turnover of professional managers of both paramedical and nonmedical categories is highly evidenced since they are not filled with necessary facilities to bring their skills out and develop both their own career and image of the organization. On the contrary, managers who are not professionally qualified retain in the hospitals for longer duration without concerning about their own career growth and organization growth and without knowing how to exhibit their skills fully and utilize resources entirely. In the study area, deficiencies such as inadequate salary, lack of professionalism, improper job description, absence of training, bias in promotion, increment and transfer, lack of interest of management towards growth of the managers and lack of motivation from top management commonly exist because of lack of development and practices of human resource management practice. As long as these deficiencies are rectified and rich support is given from management it cannot be expected productive contribution from both paramedical and nonmedical managers and their productivity level cannot be maximized.
When the productivity of the managers goes down, it can obviously be seen that morale, commitment, and performance of the subordinates would also decline. Its outcome would reveal in the form of late to the job, absenteeism, waste of resources, unnecessary chatting, long break, disobedience, negligence, disrespect and delay in response to higher officers and patients, delay in work processes, lack of teamwork, absence of communication and laziness. When these kinds of attitude are reflected among subordinates because of impaired productivity of their managers, it would definitely impact on patients and their life. When employees of paramedical employees exhibit those kinds characteristics in their work it will seriously affect the life of the patients. Although nonmedical employees do not directly involve with patients, as they support paramedical and medical personnel very significantly, their lack of commitment and morale arising out of lack of productivity of their managers' would also affect their support to paramedical and medical personnel which in turn affect entire functions of the hospital. Thus, lack of productivity of the managers not only affects their career, but also affects their subordinates, work and thus effectuates the performance of the entire hospital. As its outcome would reflect on satisfaction and life of the patents, it is necessary for the management to look for ways to enhance the productivity of the managers by analyzing what factors affect their productivity and what factors need to be corrected and what factors should be established and strengthened to enhance their productivity. In light of these reasons, this study is carried out with the aim of finding and differentiating various factors affecting the productivity of both paramedical and nonmedical managers working in private multi-specialty hospitals.

Scope of the study
The present research has focused managers working in nonmedical departments (human resource, accounting, public relation, cafeteria, security, front office, housekeeping, and maintenance) and paramedical managers (Nursing, Radiography, Medical Laboratory, Medical Records, Pharmacy) in private multi-specialty hospitals in Tirunelveli city, Tamilnadu, India. The study has studied variables called organization structure and policy, role, superior and leadership, resource and communication, managerial practice and skill, professionalism, career development, facilities, subordinates and patients, coordination and cooperation and work-home conflict.

Significance of the study
The present research has analyzed various factors which are directly associated with the productivity of the managers of both paramedical and nonmedical categories as deciding factors, so the results and recommendations of this study will help the hospital management to look into those factors and find which factor need to be corrected and which factor need to be strengthened and what kind of policy decision need to be taken to enhance productivity of the managers. The findings of this study will assist managers of both categories to assess their strength and weakness themselves in terms of leadership quality and personality and to take active steps whether to undergo training or pursue education to strengthen their leadership quality, interpersonal relationship skill, and other managerial skills which are necessary to shine in management field. Similarly, this present research will give major inputs for future research scholars who are interested to study about hospital managers and their performance, commitment, and productivity. This study will help them to get ideas as to what needs to be studied newly and what areas should be focused deeply. Thus, this research will give a strong foundation by being a source of secondary data.

Profile of the study area
The study area, Tirunelveli city, the capital city of the Tirunelveli District is located in southern part of Tamil Nadu State, India.

Objectives of the study
The following objectives have been established to guide the study:  To understand and differentiate the perception of the managers of both paramedical and nonmedical categories towards various factors affecting productivity.  To analyze and differentiate the level of perception of the managers of both paramedical and nonmedical categories towards various factors affecting productivity.  To offer suitable suggestions to enhance the productivity of the managers.

Conceptual framework
A conceptual framework containing both independent variables and dependent variables (productivity) is given below in Figure 1.

Limitations of the study
The study area is the first limitation of this present research. It has covered selected hospitals in Tirunelveli city, Tamilnadu only. It has not focused on the entire district. Type of managers studied in this research is the second limitation. The managers of non-medical and paramedical categories have been studied in this study. It has not talked about heads of medical departments. Type of hospital is the third limitation of this research. It has studied managers working in selected private multi-specialty hospitals and not focused private single specialty hospitals, government hospitals and any other health institutions such as diagnostic centres. Sampling technique (purposive) used in this research is another limitation of this research. As a result of these limitations, it is needed to be cautious when generalizing the result of this study to other kinds of hospitals and hospitals existing in other district and other categories of employees.

Literature Review
Productivity is the quality or state of being productive (Merriam-Webster cited by Casey Jo Kuykendall). It encompasses everything from reading, writing reliability, communication, reasoning, problem solving and motivation to assertiveness, judgment, leadership, team working, customer orientation, self-management and continuous learning (Payne J., 1999). Productivity is a ratio to measures how well an individual, organization, industry, and country converts input resources such as labor, materials, machines into goods and services (Hameed A. and Amjad S. 2009;Tokarcikova, 2013). It is that which people can produce with the least effort. It is the output per employee hour, quality considered (Sutermeister, 1976). It is the increased functional and organizational performance, including quality (Dorgan, 1994). It is the measure of output per unit of input economically (Nda and  The result of the study proved that training, involvement, policy, peer support, religious affiliation, ability to complete obstetric record, changes in health after posting and community involvement are the important factors determining effective productivity of the service workers. The study proved that nurses aged 35-44 were significantly more effective performers than younger and older nurses. Nurses younger than 35 years and those older than 44 years were not significant. Hameed A. and Amjad S. (2009) in their study analyzed the impact of office design on employee's productivity. The result of the study proved that lighting is the foremost factor affecting the productivity of the employees. Spatial arrangements, furniture, noise, and temperature were the next factors in order affecting productivity. Moreover, female employees were more concerned about their workplace surroundings, whereas their male counterpart was concerned about the lighting in their office followed by spatial arrangements. Result also showed that there was a direct relationship between office design and productivity. Menon M.E. (2010) in his study investigated the views of employers in Cyprus regarding the effect of education on productivity in their organization. Information was collected through in-depth interviews with 26 individuals who represented different types of employers (public sector, semi-government, small and large private organization and key stakeholders). The majority of respondents did not perceive a strong link between education and productivity nor did they consider the type of education received to have an impact on productivity. Ayila E.M. (2012) examined the influence of workplace environment on workers' welfare performance and productivity. The result of the study proved that lighting, absence of noise in the office, close office floor plan, clean and decorative office, moderate room temperature and ventilation and open office space were the workplace-related factors influencing productivity. Receiving meaningful recognition for work well done, essential information flows effectively from senior leadership to staff, job orientation for new employees, opportunity to provide input into decision that affects the work, receipt of feedback for the job done and useful feedback from the manager of superior on the job performance are the communication-related factors influencing productivity of the employees working in government sectors in Ondo state Nigeria. Rajan D. and Velanganni Joseph A. (2012) in their study analyzed the sources of stress, the impact of stress on behavior, physical health and mental health, and coping strategies being followed to deal with stress. The study analysed organization structure and policy, managers' specific, professionalism and career development, superior and subordinate, interpersonal relationship and support, role and work home conflict-related stressors. Results of the study indicated that complex hierarchies of authorities, lack of motivation, receiving the orders not only from owners but also from their family members and other relatives, monotonous and not challenging work, irritation and criticism by higher officers in front of subordinates, patients and their relatives, lack of interaction and coordination with other departmental managers, unclear job description about the expectations of the hospital as a manager are the foremost causes of stress. Overreaction and irritation to small things, difficulty in getting sleep and depression and negative thinking are the major impact of job stress. Bahadori M. et al., (2013) studied the factors affecting human resources' productivity in a military health organization. The findings of the study showed that factors such as cognitive development, organizational support, organizational culture, motivation, evaluation, ability, environment, health, training, and job clarity were among the most influential factors affecting the productivity of the human resources in any health care organization. Mahamid I. et al. (2013) investigated major factors influencing employee productivity in KSA public construction projects. The results of the study showed that the factors negatively affecting labor productivity in public construction were lack of labor experience, poor communication and coordination between construction parties, bad relations between labors and management team, payments delay by owner, misuse of time schedule to rework, labor's low wage, financial conditions of contractor, poor site management and frequent change order. Hafez S.M. et al. (2014) analyzed critical factors affecting construction labor productivity in Egypt. The study explored 27 productivity factors under four groups namely technological, management, human-labor and external. Among the factors explored, the most significant factors affecting productivity were payment delay, skill of labor, short of the experienced labor, lack of labor supervision, motivation factors, working overtime, construction manager lack of leadership, high humidity, clarity of technical specification and high and low temperature. Hickson B.G. and Ellis L.A. (2014) examined factors affecting labor productivity in Trinidad and Tobago. The study explored the factors affecting productivity under four categories namely management, technology, humanlabor and external. The study found the factors affecting productivity of construction workers were: lack of labor supervision, unrealistic scheduling and expectation of labor performance, shortage of experienced labor, construction managers' lack of leadership skills, skill set of labor, delay in responding to requests for information, payment delay, communication problems between site management and labor, rain and late arrival, early quitting and frequent unscheduled breaks. Muda I. et al., (2014) studied, factors influencing employee's performance on the Islamic Banks in Indonesia. The result of the study explained that job stress and motivation had no partial effect on the employees' performance, whereas the communication had a partial effect on employee's performance. Rajan D. (2016) in his research studied factors affecting productivity of the managers of nonmedical category in Tirunelveli city, and identified that complex hierarchical structure of authorities, unclear job description about expectations of the hospital as a manager, long instruction from the superiors that cannot be performed within the time limit, inadequate manpower in the department in accordance with the workload, lack of freedom for initiative, risk-taking and decision-making and lack of respect for own value, receiving the orders not only from owners but also from their family members and other relatives, lack of clear career path and fear of not growing and developing the personal skills, location and design of the department, long leave as well as sudden absent of subordinates that increase the work burden and affects the routine works, inadequate cooperation of subordinates and coordination among them which causes stress and anxiety and interruptions by the family members over phone after started work in the workplace were the factors affecting productivity of the managers. Anjum A. et al., (2018) in their study analyzed job productivity in Toxic work environment and the effects of a toxic workplace environment which can negatively impact the job productivity of the staff members of seven private Universities in Pakistan. The study found that ostracism, incivility, harassment, and bullying had direct significant negative effects on job productivity. The result also stated that toxic workplace has a direct significant negative effect on the job productivity of the employees. The study also observed that workplace ostracism, workplace incivility, workplace harassment, and workplace bullying reduce job productivity. Feili A., Khodaded A. and Ravangard R. (2018), in their study, 'Prioritising factors affecting the hospital employees' productivity from hospital managers' viewpoint using integrated decision-making trial and evaluation laboratory and analytic network process'. The study analyzed four clusters namely job and motivational factors, leadership and management style, environment and personal factors. The result of the study showed that employees' attitude towards the organization was the most important factor affecting the employees' productivity. Leadership and management style was the most important cluster affecting employee productivity. In the leadership and management style's cluster that involving employees in the decisionmaking process and delegation of authority to the employees were the most important factor affecting the employees' productivity. The existence of appropriate working and training facilities and equipment in the workplace and existence and equipment in the workplace and existence of intimacy and cooperation in the workplace were the least important and factors affecting the employees' productivity from environment cluster. From the reviewed literature, it could be known that study undertaken in the study area has talked about various factors affecting the productivity of the managers of nonmedical category and it has not studied productivity of the managers of the paramedical category. Hence, there is a scope to study about the productivity of the managers of the paramedical category. Therefore, this study is undertaken as a comparative study and in this study, the same variables administered to describe productivity of nonmedical managers have been applied to describe how they influence the productivity of paramedical managers in the study area in order to fulfill the gap.

Research Methodology
This empirical, quantitative and survey-based research has adopted a descriptive research design. The study has sampled 80 managers (40 from paramedical and 40 from nonmedical managers) from selected leading private multi-specialty hospitals using purposive sampling technique. From the selected respondents primary data were collected using questionnaire which was constructed based on own experience and observation of the researcher in the field of hospital administration. The questionnaire which consisted of two sections namely section 'A' that talked about demographic characteristics of the respondents and section 'B' that discussed about factors affecting productivity of the managers was made based on Likerts' five-point scale that had five attributes namely Strongly agree, Agree, No opinion, Disagree and Strongly Disagree and the attributes were allocated the values of 5, 4, 3, 2 and 1 respectively. The secondary data were collected from books, journals, thesis, projects and conference proceedings to add significant value to the study. Percentage, mean, standard deviation and coefficient of variation have been administered to analyze the data. It can be revealed from the mean score of Table 2 that the factors, inadequate pay as compared to the contribution and experience and less pay than the subordinates, sudden and unexpected changes in the working pattern and organization's policies which are hard to accept and follow and unfair performance appraisal, increment, incentives, and promotion have equally been perceived by both kinds of managers. Most of the hospitals do not have right policies with regard to HR management and they do not appoint professional HR managers and hence there is no fair system in terms of salary fixation, performance appraisal, increment and promotion and this lead to take an individual decision with regard to pay, promotion and incentives. Those managers who are closer to the directors or their relatives who can influence administration get high salary and benefits in salary increment, incentives, and promotion. Those who contribute greatly by means of introducing a lot of initiatives, better control and real development in the department are not valued because of the absence of strong HR policies.

Analysis and Results
The complex hierarchical structure of authorities is highly perceived by non-medical managers than paramedical managers. From this finding, it could be known that managers of the non-medical department are following a complex hierarchical structure. The common reason is that managers of para-medical department look after only patient care related activities. Their contact is mostly limited to patients and doctors and their administrative activities end with all patient care activities. On the contrary, although managers of non-medical department look after only supportive function, they need to deal with both patients and administrative works very elaborately beyond supportive functions. This leads them to do many activities which are not part of their job description.
Long working hours and not able to leave the duty on time due to heavy workload has been highly perceived by para-medical managers than non-medical managers. As para-medical managers mainly deal with patients and their relatives they have to look after a lot of crisis situations. As patients would come to the hospitals at any point of time and there is a long procedure of handover to the opposite shift managers, it is not possible to relieve from duty according to the relieving time. When crisis and critical situations happen, they need to remain in hospitals till the situation is completely resolved. But, this kind of situations very rarely happens to the managers of the non-medical department. Very few department managers like finance department need to stay for a longer time when crisis situations occur and all other department managers exist from the hospital after their duty time. When managers are needed to work for longer hours without adequate remuneration and flexibility in working hours and unfair treatment in pay and recognition will lessen commitment of the employees, which in turn will reflect on their contribution and performance. It can be pointed out from the mean score of Table 3 that role ambiguity and role isolation related factors have highly been perceived by managers of non-medical managers than paramedical managers. Most of the hospitals in the study area do not offer a clear job description to the managers of both categories. But, managers of paramedical do the limited work which is related to patient care activities because their whole work is fully focused on patients and so they cannot be asked to do any other work which are not part of patients related and if they are asked to do any other work it will affect patients. Due to this reason, paramedical managers are not assigned any other work mostly which are not related to patients. Moreover, as job description given to the managers is not clear and does not indicate what is expected from them by the management is not clearly indicated most of the managers just carry out the work of routine and they do not involve in carrying out any challenging and initiative work because of the unclear job description. Despite there is no clear job description, some managers who are professionally qualified involve them themselves in some initiative and risk-taking activities but others just do routine work daily repeatedly. Although what is expected from managers is not stated clearly, managers of paramedical departments involve fully in satisfying patients in all aspects since they are always dealing with patients and they are in the compulsive position to satisfy the patients, so it can be understood that they work beyond the job description.
Role overload and self-role distance have been equally perceived by managers of both categories. In third tier city like Tirunelveli where HR practice has not grown greatly, managers are assigned many tasks and they are also put as in charge for some work that is not part of their work and not part of their field also. Since they are working with private hospitals, they need to carry out them without denying it for the safety of the job. As an example, it can be said that nursing superintendent is given the additional assignment of looking after arranging uniform for nurses and look after hospital equipment and housekeeping manager should look after food arrangement for surgeons and other team members during special surgeries such as renal transplantation and cardiac surgeries. These kinds of additional assignments would really eat their energy level and hence they cannot focus on their own work and when the same is persisting it will affect their productivity level also.
Most of the hospitals do not assess skills and education suitability of the managers before they are appointed to a particular department as manager. In many hospitals, the one who has studied a bachelor degree in mathematics is appointed as an HR manager and economics degree as a public relation officer. When managers are appointed in this way, they are unable to handle the department very boldly and doubt on their own skills and feel that they do not have appropriate skills to occupy the manager post and to deal with intelligent and troublesome subordinates and emergency situations. These kinds of managers usually have less confidence though they have skills, and thus, they would not reveal their skills and capacities fully. This kind of lack of confidence will definitely affect their productivity seriously. Similarly, when the managers do not know what is expected from them as a manager from the organization, they cannot perform their duty with full capacity. When they are informed as to what results are expected from them and how quickly and with what quality, they will work towards those expectations. Otherwise, they would be working within a small circle limiting their all skills and when they work in such a way, their skills would be unutilized though they are very much skilled and knowledgeable. This kind of lack of communication from the management will confuse their work and lessen their productivity. Hence, the hospital should communicate to them about their expectation from them towards the result of the work, restructuring of work, leadership style, communication, and commitment. It can be seen from the mean score of Table 4 that the factor, huge assignments from the superiors, which cannot be performed within the time limit, has highly been perceived by nonmedical managers than paramedical managers. Generally, most of the time, nonmedical managers are given huge assignments that are not part of their work. Due to the lack of professional educational qualification, they are assigned even personal work of doctors, directors and their relatives. This kind of approach will affect their routine and make them concentrate less in their work.
The factors, negative feedback, lack of motivation, biased approach and threatening have equally been perceived by managers of both categories. Most of the higher officials do not behave maturely since the majority of the hospitals are not run by medical professionals and they do not have adequate skills as to how to appraise managers according to their skills, contribution in terms of initiative, risk and approach with subordinates and stakeholders. Moreover, they are not aware of what factors to be taken to make an assessment to decide salary increment, promotion, and transfer. In second-tier cities like Tirunelveli, there is no systematic way of appraisal followed. Those who are very close to the top officials are given salary hike blindly and those who are really contributing greatly are not given importance or skipped in giving the same. This kind of activities of top officials discourage managers and devalue them which will further interfere in their work pattern and behavior causing a negative impact in their work as well as behavior. As far as medical field is concerned, domination of the medical personnel is highly seen since they are the key people and hence all other paramedical and nonmedical managers should commonly work under the control of doctors and surgeons. Therefore, in addition to their reporting officer, they need to satisfy the need for medical personnel who are really not the reporting officer. Hence, even a small complaint given by medical personnel will shake the security of the job of the managers. Specifically, this job insecurity more seriously exists among paramedical managers than nonmedical manager since they are always closely connected with medical personnel and mostly answerable to all doctors and surgeons.
When managers always need to work with fear over their job security, they cannot perform their duty with full commitment and satisfaction and this will affect their productivity. When managers work with the promise of a job, security they can give a productive contribution. Hence, it remains mandatory for hospital management to make sure job security of the managers in order to attain productive contribution from them. Many hospitals have the practice of sending the employees out of a job even if a small complaint is made against them especially by the doctor. Hence, there should be a constant policy that deals with employee turnover.
Continuous pressure by a superior in an autocratic way for better performance is equally perceived by both kinds of managers. Putting pressure over subordinates remains mandatory to get the work done within the time limit in most of the private organizations. At the same time, it should not be done very often and if it is given continuously, it will bring about the opposite reaction from the subordinates. Targets must be achieved always by the motivated way. Since in the study area, HR system is not fully followed appropriately and healthily and there are no professionally qualified administrators and directors do not have much exposure in administration aspect, it is not known for the higher officials how to extract work from the managers. Very few people may have attitude and skills as to how to tolerate and deal with pressure given by superiors. Most of the people do not know how to bear pressure and hence they become stressed when they are given pressure in the form of over workload, new target and so on, which in turn reflect in their performance. So, management should give top-level officials training as to how to extract work from the subordinates such as qualified middle-level managers.
Close supervision by the superiors especially when working with woman employees have been reported equally by both kinds of managers. Supervision remains compulsory to get the department with discipline and get the work done according to the time limit. At the same time, when supervision is very close and constant, it will make managers uncomfortable because middle-level managers must be given some freedom and there should be faith in their behavior and skills. Some managers may take it casually, but some managers would take it very sensitively, because they may feel that confidence over subordinates by higher officials is important and when they have this kind of thought they cannot concentrate on their work and it will affect their commitment and performance. Hence, the organization should create a culture that organization always believes their employees and employees should be educated about the importance of monitoring positively. It can be shown from the mean score of Table 5 that the factors, lack of manpower, lack of data flow, poor communication and lack of updated technologies have equally been perceived by managers of both categories. Lack of manpower remains a major and primary issue in the health care industry. Unlike government hospitals, voluntary employee turnover takes place at the highest rate. Very few departments such as security and maintenance do not have high employee turnover. All other departments especially nursing, laboratory, housekeeping, reception, pharmacy and radiography departments have high employee turnover. In fact, among these departments, except housekeeping, all other departments have mostly unmarried women technicians. Marriage, husband's job transfer and delivery to a child are some of the events that cause employee turnover and these events are unavoidable and unstoppable. Hence, lack of manpower takes place very often in these departments and this leads to high stress to the managers because till hospital recruit other employees to replace resigned employees he or she has to manage and run the department with less manpower. Under these circumstances, in order to get the things done, managers need to allocate the workload over the head of an existing employee, which will consequently increase their workload further causing dissatisfaction over the job and organization. Hence, with lack of manpower in the department when managers need to perform his duty, he cannot run the department smoothly and perfectly. It will give them more stress and discomfort since he or she is the answerable person for the whole thing in the department, therefore, lack of manpower in the department will affect the productivity of the manager seriously.
Major important functions of the managers are decision-making and problem-solving. In order to carry out these functions, data are needed completely and appropriately. In third-tier cities like Tirunelveli, hospitals do not appoint professionally qualified graduates as managers and because of these reasons they do not know the importance of sharing information to other department managers and most commonly conflict and dispute can be seen in the organization. Because of these kinds of conflict, jealousy and misunderstanding, they do not share the details and necessary data, which are essential for taking the decision. For example, insurance department need details from accounts department, and without the support of accounts department, insurance department cannot prepare claim bills and cannot satisfy the patients fully, and thus, lack of cooperation and coordination in sharing data among colleague managers timely will delay decision-making and problem-solving.
Poor communication facilities to meet superiors and directors during emergency situations have equally been perceived by both kinds of managers. As hospitals deal with uncertain human beings, crisis situations may take place at any point of time, and that may happen from the patient, their relatives or employees side. As HR management practice system has not been grown to the admirable level, managers have not been authorized to take any decision on their own and all power exist with top level personnel. Hence, managers find it difficult to meet top-level officials. Naturally, technician level employees mainly deal with patients and their relatives and when these employees face difficulties and troubles, they carry the matter to their concerned managers but because of their lack of authority they cannot take, any decision and they need to wait to discuss higher officials and get permission from them. In most of the hospitals, middle-level managers cannot speak to directors directly and most of the hospitals are still not computerized. Through email or any other e-service directors or any other higher officials cannot be contacted and get a solution to the problem. Some of the hospitals have strictly made a rule that through the intercom, directors cannot be contacted. At the time, the administrators or CEO are not available in the office, this kind of rule cause delay in the decision that should be taken urgently and it causes the patient dissatisfied. Thus, lack of manpower, lack of data flow, poor communication and lack of updated technologies impair the productivity of the managers directly, management should pay attention over these issues and try to resolve all these matters in order to give managers comfort zone to work and bring their abilities out. It can be indicated from the mean score of Table 6 that, all factors discussed in this managerial practice and skill related factors have been equally perceived by managers working with both disciplines. In most of the hospitals, top-level personnel such as chairman and directors who are medical personnel possess all authorities. They decide everything in the hospital and managers are just working as executives and they are not given any authority to take any decision to introduce any innovative ideas, to take any initiatives and risks. They have to just execute what directors or chairman dictate. Very few hospitals which run in corporate set up give authority for their managers to decide recruitment and decide fee concession, employees' salary, and leave and so on.
As the hospital industry remains doctors dominated industry and all decisions are taken mostly by doctors, any innovative ideas, opinion and managers who wish to take the risk to improve hospitals are not valued. This kind of discouragement dissatisfies managers and devalues them, which further deteriorate their productive contribution to the hospitals. Furthermore, in second-tier cities, like Tirunelveli, most of the hospitals do not have solid guidelines as to how to solve the problem, which arises from patients, subordinates and other departments. They have not been given adequate authority also. Hence, they need to depend on directors for all kinds of problem to be taken decision about and sorted out. These kinds of lack of authority and insufficient guidelines affect managers when the higher officials are not available and hence they cannot solve the problem and take decision resulting in dissatisfaction of patients and subordinates over the managers.
Moreover, the hospital is an industry in which uncertain human being are dealt with. It cannot be predicted when patients will become emotionally imbalanced and express their anger. Example sudden death of the patient and worsening of the conditions of the patients will make their relatives very angry. Some of the patients will suddenly express their anger if they are made waiting in any one of the departments of the hospital. Hence, in order to tackle these kinds of situations, managers need to possess adequate skills and confidence over their skills, and also adequate authorities are essentially needed to express their contribution towards satisfaction of not only the patients but also subordinates and organization. Hence, hospitals should come forward to develop their skills and ability and also delegate authority in order to develop their career and thereby reveal their skills productively towards the growth of the organization. Thus, because of the lack of adequate skills and lack of guidelines and authority, managers find difficult and scared to communicate with higher officials freely and soundly whenever the need arises to speak with superiors. This kind of inadequate skills and authority their performance level also get affected. So, management should hire managers who have adequate and enough skills and give them enough authority to deal with situations arises in hospitals, and then only their productivity level will become higher. It can be understood from the mean score of Table 7 that, the factors, receiving the orders not only from owners but also from their family members and other relatives, to carry out some duties assigned by doctors, directors and other higher officers that are not part of the duty, criticism of the management with disrespectful words and being seen suspected and performing non-professional tasks (being asked to do the personal work of superiors and doctors) have been highly perceived by managers of non-medical department than para-medical department. As far as a private organization concerned, it can be commonly seen that the influence of relatives of directors or chairman who does not have any authoritative role in administration, but their influence would be huge in many activities of the organization. Because of this informal influence, mostl managers of nonmedical category especially managers of public relation, front office, security, canteen, finance are highly affected. As managers of the paramedical department are always connected with patient care area they are rarely influenced.
In developing and unsystematic organizations, as there is no appropriate and clear job description stating what they should do and what they should not do, they are given workload which is not a part of their job position. Most of the chairman and their relatives use managers to perform their own personal and household work such as booking flight, train ticket, taking and dropping their children to school, college and paying their insurance and telephone bills. These kinds of works are not allocated to managers of paramedical discipline. In addition to chairman and their relatives, medical personnel also use manager of the non-medical department for their personal use. As hospitals remain doctors dominating industry top management also do not authoritatively stop this kind of informal personal work given by medical personnel to managers. Very rarely this kind of personal work is allocated to managers of the paramedical department. Moreover, managers in most of the hospitals are criticized very badly without proper respect. Their education qualification and submissive attitude to retain their job are some of the reason for their lack of respectful approach towards them.
The factors, negative comments by higher officers in front of subordinates, patients and their relatives, inadequate infrastructure and opportunity to practice professional managerial job and lack of professional respect from higher authorities and activities of the higher officers and Directors of contacting the subordinates bypassing the managers and office politics have been equally perceived by managers of both kinds. The approach of the superior with managers is not professional in most of the private hospitals. Both paramedical and nonmedical managers are equally affected by this lack of professional approach towards middle managers. Most of the higher officials scold managers of both kinds very inferiorly and negatively even in front of patients, relatives and other employees. Most of the top officials do not realize if they are negatively commented on how their subordinates would respect them and how they would carry out the tasks allocated by managers. Most of the managers very submissively tolerate this kind of negative comment for their family, financial situations and unemployment conditions existing in the market. But, though they tolerate those humiliations and move submissively, it creates stress in them and it will affect their work and lose their commitment and productive contribution towards the organization. Hence, management should learn how to respect the professionalism of the managers and treat them in all ways especially in front of their subordinates, patients and their relatives. In all way, management should respect their education and position and try to get work in a decent way from them. It can be known from the mean score of Table 8 that, all factors discussed in career development related dimension have equally been perceived by managers of both categories. From this strong response, it could be understood that managers of both categories are working without any platform for their career growth in their hospitals. Firstly most of the hospitals do not have any strong policy related to the training and development of their employees. For them, managers are just the employees like others and they have to do the tasks allocated to them by directors. In most of the hospitals, managers do the same work repeatedly and management also wants them to do those kinds of works, so, their work exist like monotonous work and this kind of repeated monotonous work does not lead them to take any initiative and risks in their job. As most of the hospitals are run by doctors and they believe that patients also arrive in the hospitals just for the doctors' fame and during emergencies, doctors want managers to carry out what they say by being a supportive force.
As hospital owners have this kind of thoughts, they do not like to spend money on training and development of managers. Very few hospitals where some transplantation surgeries are taking place, they send their managers for training since it is compulsory according to the rules of government. When compared to nonmedical managers, paramedical managers are getting training little. They, especially nursing managers are allowed to attend training and development programmes in some of the medical colleges and other institutes which is being organized by some pharmaceuticals.
When they do same monotonous work repeatedly without getting any opportunity to update their knowledge about their field, their skills, and knowledge, they will be accustomed to doing the same routine works and feel that that are their only job and they will not take any effort to develop their growth. At last, they will start living within a small circle. In third-tier cities like Tirunelveli, almost very highly qualified managers do not like to work and those who just acquire a degree and master degree from ordinary colleges join in the hospitals as managers and they are fully satisfied with the work they are assigned by their superiors with the designation of managers. Most of the doctors who run hospitals think that if money is spent for training and development after they learn they will leave to another hospital and due to this kind of thoughts, they just like to keep managers as ordinary employees. Due to these kinds of thoughts of the doctors and hospital owners, they are not utilizing the skills of their managers fully and it will affect the growth of their organization. Therefore, management should understand that training and development only will bring managers' skills out and then only they will work productively by taking initiatives and risks and thereby reputation of the organization and profit will grow up. It can be viewed from the mean score of Table 9 that location and design of the department and the ventilation and temperature level of the department have been highly experienced by managers of the non-medical department than the paramedical department. In most of the hospitals, nonmedical departments especially human resource, finance, material, insurance, and public relation are located either in top floor or underground and they are not facilitated with air-conditioning facilities and those who are in top floor undergo serious temperature problem and at the same time those who work in underground floor are troubled with ventilation problem. When compared to nonmedical, paramedical departments are set up with air condition and full ventilation facilities since they are dealing with patients and other equipment that are needed to be under airconditioning conditions, so, managers do not expose to the challenges of high temperature and ventilation as nonmedical managers.
The factors, absence of lift facilities, inadequate space in the department and poor furniture and inadequate welfare facilities have been equally perceived by managers of both categories. From these responses of them, it could be understood that they are suffering hugely without adequate space and good furniture in their department. A number of the hospitals do not have lift facilities and though they have had they do not allow their employees to use the lift and this kind of policy not only make them discouraged but also reduce their productivity level because when they need to climb steps number of times they will reduce their energy level and cause tired. Many hospitals have their administrative set up in a congestive manner and the manager cannot even sit comfortably and furniture such as chair and desk are not of comfortable and big enough in size and these kinds of treatment will not bring their skills out in such a way that they contribute very productively.
Similarly, welfare facilities such as canteen and restroom are not of high standards. Though canteen is available in the hospital, a separate place is not allocated for managers and in the same way separate toilet rooms and drinking water facilities are not provided for managers. They need to take food commonly with other patients and need to share common restroom with other staffs. In some of the hospitals, it can be commonly seen that managers need to share toilets with patients. These kinds of substandard treatment of the managers will not create superior thoughts among their subordinates and patients about managers and also deteriorate their respect among them. Moreover, these kinds of substandard facilities will question their values and lessen their contribution towards the organization. Hence, management should concentrate on developing facilities for the managers so that they can work productively and maintain their privacy and professionalism. It can be observed from the mean score of Table 10 that the factors, cooperation and subordination of subordinates are crucial for better output in the department, at the same time, when they are negative and opposite in nature disputes, misunderstanding, and office politics would be the result in the department. All factors discussed under this subordinates and patients related factor except dependent patients and emotionally imbalanced patients have equally been perceived by managers of both categories. Most of the hospitals appoint employees based on their own recommendation, community, caste, and religion. When employees are not appointed based on qualification and quality and when they are appointed based on the recommendation of the higher officials, it is obviously putting managers in tougher situations to control them. Most of the hospitals do not even discuss with managers about their requirements in terms of a number of manpower and their qualification and the managers are in the position to lead the employees who are appointed by directors. Since most of the employees are appointed on the basis of the recommendation of directors, few of them are in contact with top officers and hence they usually do not listen to managers and obey their orders.
Most of the hospitals are recruiting employees for lower level management especially from local areas and when large numbers of employees are taken in these way managers find difficult to control few of them. They join together in the name of community and religion sometimes. So, managers need to be very careful to deal with these kinds of employees especially at the time of salary increment, punishment and transfer they may involve in the strike and purposefully absent as group for the duty. This kind of fear always makes the manager be very submissive sometimes and it will affect their performance also. Hence, management should avoid hiring a large number of employees from a particular community and trying to hire employees from different communities, religion, and areas. This is not only a diversify force but it also helps employees to learn from each other. Besides, the manager should learn how to handle those employees without issues and management also should provide them with training. Another important factor which disturbs managers not to work freely is the employees who work for a longer period of time. Few employees who have been working for longer duration in the hospital sometimes do not support and cooperate to the manager. It sometimes causes delay to the manager to complete their tasks. Hence, the manager should develop leadership quality very richly as to how to handle experienced people in such a way that it does not affect their self-esteem and at the same time get tasks completed completely and perfectly. Management should also be very strict in their policy of subordination in insisting all employees obey to manager's order and work only towards the interest of the organization.
Dealing with dependent and emotionally imbalanced patients has highly been perceived by managers of a paramedical category than nonmedical category. It is due to the reason that paramedical managers primarily and always deal with patients and their relatives of different nature. Hence, they need to deal with all kinds of patients compulsorily but nonmedical managers though deal with patients they have some limitations and very rarely nonmedical managers deal with patients during a crisis situation. It is the nature of the patients to become imbalance very often while they are in treatment and unless the managers have adequate skills and calibre to manage them, they will lose their temper and they will become imbalanced and develop stress, which will eventually impair their performance. Therefore, the management should pay attention to develop skills of both paramedical and nonmedical managers as to how to deal with patients who are emotionally imbalanced and how to handle them during crisis situations. It can be shown from the mean score of Table 11 that the majority of the managers from both categories have shown equal perception towards cooperation and coordination related factors. From this response, it could be understood that cooperation and coordination among the managers of different departments are not healthy and there is some lack in it. Strong cooperation among managers of all departments and categories is crucial to deliver fully satisfied services for the patients since all task in medical service is fully teamwork-based. Misunderstanding and conflict lie common in all organization but when employees behave with the same thoughts in mind for a longer time it will deteriorate their work in the organization. Egoism is the primary factor causing conflict among the managers and it exists among all level and departments. Medical personnel think they are everything in the hospital and next to them paramedical personnel think that they are the biggest people and among the departments different managers think they are the powerful people and so others should come to them and they should not go to others. As they think and behave in such a way there is always egoism existing invisibly and it affects the work of all managers.
Most of the time medical personnel do not support the managers of both paramedical and nonmedical categories. Some of the managers most of the time need to depend on doctors to carry out their job. For example, manager of the radiography department needs doctors to give intra venous injection to the patients for taking some specific type of X-ray and similarly manager of medical records department need doctors to write discharge summary for the patients. When doctors do not cooperate timely it will affect their work and they will have to deal with patients who will not be ready for waiting and those who are emotionally imbalanced. Sometimes, more delay that takes place at doctors' side, even would lead to crisis situations. For example, if doctors do not visit the radiography department to give intra venous injection to the patients and do not release discharge summary report on time, patients start showing their disappointment initially by quarreling with managers and it some patients goes up to hitting employees.
Besides, lack of cooperation and coordination can be largely seen among managers of the same category and it delays the work of other department and at last affect the result of patients in the form of delay and dissatisfaction. Strong cooperation should exist between insurance and accounts departments and then only claim bills can be released to the insurance department. Instead, if there is an absence of cooperation and communication between these two managers, it will definitely make delay in sending claim bill to the insurance company and clear the amount. This kind of lack of cooperation and coordination among managers of various departments of the same category and other categories and other levels not only affect the productivity of their own department but also affect managers of other departments. Lack of understanding and communication among the managers and not knowing their responsibilities wholly are the reasons for this either absence or lack of cooperation. Management should conduct frequent meeting joining managers of all department and assert them the importance of teamwork and lose that would happen because of lack of cooperation and coordinated work among them and how it will affect organization and patients. In order to develop their team spirit very often entertainment and business games should be arranged by management. It can be indicated from the mean score of Table 12 that managers of both categories have revealed the same perception towards work-home conflict-related factors. From this response, it could be known that managers of both categories are in the position of not knowing how to balance both their work and home life equally in such a way how one does not affect another and they are in need of training and education as to how to balance both lives equally. As the hospital industry need round a clock service and it deals with mostly uncertain human being, it cannot be predicted what will happen next. As, at any point of time, emergency situations may occur, so the manager cannot relieve duty as per schedule and sometimes they may need to work beyond the duty hours. Definitely, it will interrupt their family life. As far as private hospitals are concerned, it is common to receive a phone call from the hospital even after managers go home, and it is unavoidable because the person coming to next shift may need any information about the patients sometimes and at that time he would get it only by a phone call.
When manager needs to work beyond working hours, it is needed for hospitals that they should be flexible in timing but most of the hospitals do not look at seriously at what time the manager leave duty and they see very cautiously at what time they come to duty. This kind of approach of the management very often hurts the manager and creates anger and stress to them and it further leads to lack of commitment and thereby productivity. Personality type of manager is also the reason for work-home conflict of them because some personality type of managers takes all pressure they face in workplace very easily and forget it in the workplace itself and they do not take home. But there is some type who takes issues of the workplace to the house and show their stress and anger over their family members and they always fill their mind with work-related thoughts and find difficulty in sleeping. Similarly, they are always obsessed with family-related issues and they show it in the workplace on subordinates and colleagues and thus when they work with this kind of obsessed mind without able to balance both home and work they cannot perform their work efficiently and perfectly. As the inability to balance both home and work life equally affect the productivity of the managers, managers should give them education emphasizing how to balance both work and family life equally in such a way one should not affect another. It can be advocated from Table 13 that the factors, organization structure and policy, superior and leadership, managerial practice and skill, career development, coordination and cooperation, and work-home conflict have been equally perceived by managers of both categories. Role, professionalism and facilities related factor have been highly perceived by managers of the nonmedical category. The factor subordinates and patients have been highly perceived by the paramedical manager. In it, only patients' related factors have been highly perceived by paramedical managers but subordinates related factors have been highly perceived by managers of the nonmedical category. The difference of perception of managers of both paramedical and nonmedical categories is given below in Figure 2.

Discussion
The present research observed that inadequate salary, bias in the promotion, performance appraisal, salary hike, transfer and promotion and also lack or absence of recognition are the factors affecting the productivity of the managers of both paramedical and nonmedical categories. These findings concur with the study of McForsen and Joyce Essel (2012) who has proved that low salaries, irregular promotional structure and lack of recognition of workers achievements are the factors dampening workers morale and productivity. In this present research managers of both kinds revealed that lack of motivation and recognition affect their productivity. This result provides support for the result of McForsen and Joyce Essel (2012) who observed that level of motivation and the effectiveness of the workforce will also affect the performance of the labor productivity.
The present research indicated that inadequate support of the superiors during emergency situations and autocratic leadership style of the superiors are the factors affecting the productivity of the managers. This finding is similar to the study of Bui TrungKien (2012) who stated bad leadership skill, poor relations between labor and superintendents and lack of labor surveillance are the factors of affecting productivity. Managers of both kinds in the present research indicated that work environment such as office design, ventilation and lighting are the factors influencing productivity. These findings In the present research inadequate incentives, unsupportive leadership style, inadequate career development opportunities, and physical environment have been identified as the factors of affecting the productivity of the managers of both kinds. These findings go along with the study of Mehrabiyan F. and Nasiripora S. (2011) who advocated in their that culture, incentives, environment, personnel strengthening, and leadership style are the most important factors affecting productivity. It has been identified in the present research that unfair reward system, lack of training and development methods, complex organizational structure and physical design of the office are some of the factors affecting the productivity of the managers of both kinds. These findings are corroborated with the study of Allahverdi et al. (2010) who have observed that person-related variables, culture, organizational structure, rewarding mechanism, training programs, and the physical context affect productivity.

Suggestions
Based on the findings of the study, the following suggestions are given to enhance the productivity of the managers of both paramedical and nonmedical categories.
 Working hours can be regulated. It is suggested to reduce it from 12 hours to 8 hours. The managers should be provided with sound job descriptions that state their roles and responsibilities and what the management expects from them clearly. Decent salary should be given in accordance with their contribution, skills expressed, risks taken and their experience. Managers should be allowed to participate and give their views when management make any changes in their policies and procedures which are related to their department. A workplace should be made comfortable with adequate space, lighting, ventilation and restroom for both male and female managers separately in the hospital.
 Managers should be motivated by fair and transparent performance appraisal, feedback, increment, promotion, and reward. They should be supported by the superiors at the time of crisis and when they are struggling to make decisions. Higher officials and superiors should follow supportive and participative leadership approach rather than an autocratic approach to get work from the managers. The managers should be encouraged constantly to get productive work instead of threatening them by taking job security as a threatening tool.
 The manpower should be appointed in accordance with the workload in the department. All departments should be encouraged to share the information with other departments that is essential to make a decision. A modernization should be made. As part of this, an adequate number of computers should be provided with internet facilities so that paperwork can be reduced and information flow can be faster. Communication facilities should be strengthened to meet superiors at the time of crisis and other emergency situations.
 The managers should be given adequate authority according to the responsibilities and position they have occupied. Freedom should be given with constant encouragement to take the risk, introduce initiative ideas and take decisions boldly. With respect to decision-making, clear guidelines should be established and explained to them. Moreover, training should be given to the managers as to how to comply with employees who speak negatively, behave emotionally imbalanced and gossip deliberately.
 The hierarchical structure should be established clearly and all communication flows through it strictly. Managers should receive the order from superior and pass the command to their subordinate as per the established hierarchy. Higher officials should communicate to the departmental subordinates through managers. They should not bypass managers and communicate subordinates who are working in the department unless it is very emergency one. Professionalism should be maintained in the hospital strongly and the managers should not be given personal work of the higher officials and doctors as it affects their professional respects. The management should follow constructive criticism to point out managers' mistakes to value their self-respect. The management style should create a platform for professional management.
 Consistent attention should be paid on the career development of the managers. Through continuous management development programme, position rotation and challenging assignment in order to update their professional skills such as decision-making, problem-solving, initiative, risk-taking and innovative skills and also develop their soft skills such as communication, cooperation, coordination, assertiveness, and team spirit should be established. Managers should also be trained how to balance both family and work life and how to avoid and overcome stress occurring in the workplace. Management development program should include various managerial techniques such as sensitive straining and management games so that managers of different discipline such as medical, nonmedical and paramedical should work together as a team.
 Requests and proposal of the managers towards the appointment of manpower and transfer of employees and disciplinary action against the subordinates who are disobedient should be considered seriously without any discrimination.

Directions for future research
This present study provides multiple directions for future research scholars to begin their research. In the same way of current research, factors of affecting the productivity of employees working in paramedical and nonmedical departments instead of managers can be studied. Future research can be undertaken about factors affecting the productivity of the heads of medical departments. Future research can also be undertaken as a comparative study-adding managers working in single-specialty hospitals and diagnostic centres. This present research can be extended to the whole district and another district also.

Conclusion
The aim of this empirical, quantitative and survey-based descriptive research undertaken in Tirunelveli city, Tamilnadu is to understand and differentiate perception of the managers working in non-medical and paramedical departments in private multi-specialty hospitals towards various factors affecting their productivity. The study has analyzed eleven main variables namely organization structure and policy, role, superior and leadership, resource and communication, managerial practice and skill, professionalism, career development, facilities, subordinates and patients, coordination and cooperation and work-home conflict to understand their perception. The study has sampled 80 managers (40 from paramedical and 40 from nonmedical categories) using purposive sampling technique. Primary data have been collected using structured self-made questionnaire. Secondary data have been collected from books, journals, and websites. Mean, standard deviation and coefficient of variation have been administered to analyze the data. The results of the comparative study indicate that the factors, organization structure and policy, superior and leadership, managerial practice and skill, career development, coordination and cooperation, and work-home conflict have been equally perceived by managers of both categories. Role, professionalism and facilities related factor have been highly perceived by managers of the nonmedical category. The factor subordinates and patients have been highly perceived by a paramedical manager with little variation. As the productivity of the managers of both nonmedical and paramedical play major role in ensuring profits and reputation of the hospitals, it is essentially needed for hospital management to take necessary steps including policy decisions to enhance the productivity of the managers of both categories and thereby ensure offering safe and quality services for the patients.