ABSTRACT
Globally, the topic of policy is very critical and has received considerable attention among scholars, though very limited in issues of attitude of healthcare personnel and its effects on a critical segment, the nurses. Specifically, the study investigated the effects of policy on nurses’ work attitude and patients’ satisfaction with service delivery in Nigerian teaching hospitals. This was done by looking at the relationship between policies and attitude of nurses, the relationship between the attitude of nurses and service delivery. It also examined the relationship between attitude of nurses and patient’s satisfaction as well as the relationship between service delivery and patients’ satisfaction.
Survey design, which included administration of structured questionnaires (quantitative) and in-depth interview (qualitative) were adopted. Out of the 400 questionnaire that were administered using convenience sampling technique, a total of 285 (69 from BUTH and 216 from LUTH) were returned. The research questions were structured in such a way as to gather from the nurses, pertinent and specific information on the effects of policy on their work attitude on one hand and patients’ satisfaction of service delivery on the other hand. The responses were analyzed using descriptive analysis (percentages and mean score) and the inferential analysis (Regression). For the in-depth interview, open-ended questions were administered on patients, patients’ relations and Management Officers from the two study hospitals, with the use of tape recorder. The data collected were transcribed and analyzed using content analysis.
The results showed the correlation coefficient (0.360) indicating a positive and statistically significant relationship between policies and attitude of nurses. It also showed the correlation coefficient (0.605) indicating a positive and statistically significant relationship between attitude of nurses and service delivery, as well as the correlation coefficient (0.630) indicating relationship between attitude of nurses and patients’ satisfaction. The results also showed the correlation coefficient (0.643) indicating a positive and statistically significant relationship between the service delivery and the patients’ satisfaction.
The study concluded that the hospital management in particular and by extension, the government, carry out regular orientation and training, increase nurses’ incentives and welfare packages, introduce system of close monitoring and supervision of nurses , as well as putting in place regular feedback mechanism from patients on their experiences as they access service in the hospitals. The government and management should tackle the deficiency of fund and recession which affect the number and quality of equipment at the disposal of all professionals in the hospital. Finally, there should be regular review and evaluation of the policies to ensure that set out objectives are achieved. This study contributed to knowledge by empirically establishing that policy has a major effect on the work attitude of nurses and should be given a broader attention.
Keywords: Nurses, Patients, Policy, Satisfaction, Service Delivery, Work Attitude.
Word Count: 448
TABLE OF CONTENTS
Content Page
Title page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract vi
Table of Contents vii
List of Tables x
List of Figures xi
List of Appendices xii
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 6
1.3 Objective of the Study 8
1.4 Research Questions 8
1.5 Hypotheses 9
1.6 Significance of the Study 9
1.7 Scope of the Study 9
1.8 Operational Definition of Terms 10
1.9 Chapter Outlay 11
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 12
2.1 Policy 12
2.2 Health policy 14
2.3 Hospital policy 15
2.3.1 Educational development 16
2.3.2 Wage and salary 17
2.3.3 Nurse to patient ratio 17
2.3.4 No work, no pay 18
2.4 Attitude and work attitude 18
Content Page
2.4.1 Causes of employee attitude 19
2.5 Service delivery 21
2.5.1 Health care service delivery 23
2.6 Employee performance 25
2.6.1 Employee participation and performance relationship 27
2.7 Patients’ satisfaction 28
2.8 Health sector organization and their environment 29
2.8.1 Conceptual model 31
2.9 Empirical review 33
2.9.1 Attitude and service delivery 33
2.9.2 Motivation and service delivery 35
2.9.3 Management and service delivery 37
2.9.4 Service delivery through patient-centred care 39
2.9.5 Barriers to patient-centred care 41
2.10 Theoretical framework 43
2.10.1 Motivation theory – Herzberg two factor theory 43
2.10.2 Behavioral organizational theory 46
2.11 Gap in Literature 48
2.12 Conclusion 49
CHAPTER THREE: METHODOLOGY
3.0 Introduction 51
3.1 Research design 51
3.2 Population 51
3.3 Sample size and sampling Technique 52
3.4 Instrumentation 53
3.5 Reliability test and validity of instrument 54
3.6 Method of Data Collection 54
3.7 Method of Data Analysis 55
3.8 Ethical consideration 55
Content Page CHAPTER FOUR: DATA ANALYSIS AND DISCUSSION OF FINDINGS
4.0 Introduction 56
4.1 Socio demographic analysis of respondents 56
4.2 Analysis of questionnaire items 60
4.3 In-depth interview 71
4.4 Test of hypotheses 77
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Summary 85
5.2 Conclusion 85
5.3 Recommendations 86
5.4 Limitation of the Study 86
5.5 Contribution to Knowledge 86
5.6 Implications for Policy 87
5.7 Suggestion for Further Studies 87
REFERENCES 88
APPENDICES 96
LIST OF TABLES
Table Page
- Summary of reliability test 54
- Socio Demographic data of the respondents 56
- Questions addressing Policies 60
4 Questions addressing nurses’ work attitude 64
5 Questions addressing patients’ satisfaction 66
- Questions addressing service delivery 68
- In-depth interview guide 71
- Regression result for policies vs nurses’ attitude 77
- Regression result for nurses’ attitude vs service delivery 79
- Regression result for nurses’ attitude vs patients’ satisfaction 81
- Regression result for service delivery vs patients’ satisfaction 82
LIST OF FIGURES
Figure Page
1 Conceptual Model 31
2 Herzberg’s two factor theory 45
LIST OF APPPENDICES
Appendix Page
- Raw Pilot Study data 97
- Informed consent form 98
- Questionnaire for nurses 99
- In-depth interview consent form 104
- In-depth interview guide 105
- Turn it in report
CHAPTER ONE
INTRODUCTION
- Background to the Study
Despite bold plans and massive injections of international and domestic resources, public service delivery is still failing in many areas in several developing countries. This according to Mcloughlin and Bately (2012) suggests there is a need to revisit approaches to rendering assistance to service delivery sectors. It is also necessary to focus on understanding how a range of institutional and governance arrangements can shape service delivery processes and outcomes. They went further to say that while the number of political economy studies on different service delivery sectors and different countries is growing, these remain largely one-off or ad hoc studies. Thirdly, their study tends to talk in fairly generic terms about political and governance constraints. For example, concepts like ‘political will’ or the existence of ‘weak incentives’ are often referred to but rarely further developed in terms of the specific institutional and governance arrangements that contribute to these factors, and in terms of which of these may offer strategies for overcoming common bottlenecks or gaps ( Mcloughlin, Batley, 2012). Therefore, the justification for a service delivery reform may lie on the need for efficiency, effectiveness, and accountability (Lufunyo, 2013)
The tools and strategies used by stakeholders to achieve their policy objectives have also evolved and it is now common place to refer to governance as a range of old and new tools and instruments through which public policy goals may be achieved and/or delivered (Zito, Radaelli, Jordan, 2003; Hood, 2006). The very concept implies that the ways to govern the public sector and the tools for doing so have changed (Salamon, 2002) and – implicitly or explicitly – should change further from old command-and-control, public administration or management models (Bovaird, Löffler, 2003). The importance of policy or its implementation cannot be overemphasized particularly as it relates to health. This is because health is an essential component of development, necessary for a nation’s economic growth and internal stability. It is a necessity for everyday life, not the object of living, but a positive concept emphasizing social and personal resources as well as physical capabilities. This may be said to explain the popular saying that a healthy nation is a wealthy nation. It is further emphasized by the definition of World Health Organization (WHO), (1946), that good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.
To ensure that everyone has access to quality health, the Universal Declaration of Human Rights (1948), recognizes health as a fundamental human right. This means that the relief or cure of ill health is universally important and this makes it imperative to ensure that high quality services are provided in response to developments in medicine and the desire of the caring professions to aspire to clinical excellence (Sewell, 1997). Governments therefore have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. It may not be wrong therefore for one to reason that health and healthcare delivery can be viewed from a system perspective characterized by complexity and interconnectedness, where everything affects everything else.
Healthcare in communities and hospitals have become increasingly important, even as they face fundamental changes in their service delivery patterns (McKee & Healy, 2002; Lee, Chen & Weiner, 2004). The hospitals are governed by a set of processes and tools related to decision-making in steering the totality of institutional activity, influencing most major aspects of organizational behaviour and recognizing the complex relationships between multiple stakeholders otherwise called policy (Richard, Saltman Antonio Durán Hans, & Dubois, 2011). The policies governing hospital according to Ricard et al (2011) has a scope that ranges from normative values (equity, ethics) to access, quality, patient responsiveness, and patient safety dimensions. It also incorporates political, financial, managerial as well as daily operational issues.
In view of the foregoing, issues in healthcare need to be viewed holistically as integrated system of multiple components (people, organization, technology and resources) and perspectives (Health Systems, 2012). In furtherance of this, several researchers have posited on the challenges faced in the provision of evidence-informed health care, one of which is the right intervention to the right people at the right time in routine settings. While Marchal, Cavalli, and Kegel, (2009), Green and Collins, (2003) have observed that this challenge is particularly acute in low income settings, English, Ntoburi, Wagai, Mbindyo, Opiyo, Ayieko,…Irimu (2009) have gone on to describe the specific major failures in hospital care in Africa.
Here in Nigeria, staff attitude has been attributed to the poor health care delivery (Akerele, 1986; Maduabum, 1990; Afolabi & Erhun, 2003). Affirming this, the Federal Ministry of Health (2007), reported that the poor state of Nigeria’s health system is traceable to several factors; organization, stewardship, financing and provision of health services.
Attitude is an internal state that influences individual’s choices of personal action (Bianey, Ulloa, Adams, 2004). The attitude of the health care employee can affect service delivery either positively or negatively. In other words, attitudes are good predictors of behavior and they provide clues to an employee’s behavioral intentions or inclination to act in a certain way. According to Newstrom (2001), positive job attitude helps predict constructive behaviors, while negative job attitude helps predict undesirable behavior. Employee attitudes and behaviors are important factors in service encounters, with committed employees, particularly the frontline staff, linked with increased levels of customer satisfaction (Ballout, 2007). This is to ensure that organizational values such as the provision of quality service is established and sustained.
The Royal College of Nursing of the United Kingdom (GB) explains the difference between a professional nursing attitude, which is, values nurses hold as well as their thoughts and feelings; to behavior, which is what nurses actually do. It is therefore suggesting that a factor like working environment can prevent nurses from enacting their professional values, while affirming that sometimes things can go wrong. In hospitals, interaction between nurses and stakeholders has always been critical in determining whether patients experience satisfaction or dissatisfaction in the provision of inpatient and outpatient healthcare services (Zangaro & Soeken, 2007). The provision of poor-quality care has often been attributed to inadequate knowledge and skills compounded by broader system failures and low staff numbers. This has given rise to the need to tackle inadequate human resources for health (HRM), which also was noted as an essential part of strengthening health system and emphasized in the 2006 World Health Report.
However, the focus of attention has been on macro-level issues related to workforce, training, recruitment, retention, skill mix and distribution. More recently, attention has turned to the capacity of health workers, their motivation and other structural and organizational aspects of systems that influence performance than ways to satisfy the needs of the patients (Bradley, Youngkyoo, Cook, Sache, Donabedian, 1996). Notwithstanding the catalogue of researches carried out on the healthcare delivery system and several recommendations proffered, the perception of Nigeria’s hospitals, particularly the public ones are still very far from being impressive.
The aim of this study is to highlight the effect of service delivery policy on the work attitude of nurses and go on to investigate how this affects patients’ satisfaction in two Nigerian hospitals, Lagos University Teaching Hospital (LUTH) and Babcock University Teaching Hospital (BUTH). Both hospitals come under tertiary or referral hospitals which provide health care by different specialists after referral from primary care or secondary care centers.
A tertiary or teaching hospital is a hospital or medical center that provides clinical education and training to future and health professionals. Teaching hospitals are often affiliated with medical schools and work closely with medical students throughout their period of matriculation and especially during their internship. In most cases, teaching hospital offer Graduate Medical Education (GME), physician residency programs, where medical school graduates train under a supervising specialist to assist with the coordination and provision of highly specialized clinical care to the most severely ill and injured. In addition to this, many teaching hospitals also serve as research institutes. Teaching hospitals exist under two categories – public and private. A public teaching hospital or government hospital is a hospital owned by government and receives government funding. In some countries, this type of hospital provides medical care free of charge, the cost of which is covered by government reimbursement. In Nigeria, the cost of treatment is not entirely free but highly subsidized. An example is the Lagos University Teaching Hospital.
Lagos University Teaching Hospital started in 1962 with three hundred beds but today has more than eight hundred beds and has through the years provided health personnel to Nigeria’s health sector with about 32,488 doctors and more than 3,819 nurses having undergone training in the institution. When it took off, LUTH had ninety four nurses of all cadres in its employment and by its 50th anniversary in 2012, it had seven hundred and twenty seven nurses comprising of, Assistant Director, Nursing Services (1), Chief Nursing Officers (119), Asst. Chief Nursing Officers (112), Principal Nursing Officers (142), Snr. Nursing Officers (52), Nursing Officer (8), Nursing Officer 1 (60), Nursing Officer II (72), Staff Nurse Midwife/Nursing Sister (99), Midwife Sister/ Nursing Supt. (6), Temp. Staff Nurse/Staff Nurse/Staff Midwife (57).
Mrs Adewunmi, one of the first nurses of LUTH in an interview in 2012, described the nurses’ relationship with patients at that time as friendly. This is exhibited such that twenty five years after retirement and fifty years after the inception of the hospital, she could still remember the name of the first surgical patient of the hospital as Mr. Apanisile, who according to her, after his hospital discharge sought and got employed as the hospital’s barber for many years. To the nurses at that time, the patients came first in the hospital and because they were well looked after, patients enjoyed coming to the ward/ hospital.
A private teaching hospital is a hospital owned by a private university and privately funded through payment for medical services by patients themselves, by insurers, governments through national health insurance programs, or by foreign embassies. An example is the Babcock University Teaching Hospital established by the Seventh Adventist Church, and an upgrade of the former Babcock University Medical Center. it officially took off in 2011 with a total of 34 nurses and by 2015, the number had increased to 178. This is made up of, Director of Nursing Services (1), Chief Nursing Officers (6), Assistant Chief Nursing Officers (7), Principal Nursing Officers (11), Nursing Officers 1 (13), and one hundred and Nursing Officers (135).
Observably, the highest cadre, chief nursing officer, in the Lagos University Teaching Hospital, has the highest number of nurses, 119, as against the highest number of 135 nurses being in the lowest cadre, nursing officer, in the Babcock University Teaching Hospital. It may be pertinent to also note that that the nitty gritty of the nursing care is usually undertaken by the nursing officers while the chief nursing officers act mostly as supervisors.
- Statement of the Problem
The role of policies in shaping and guiding employees’ actions in organisations such as the teaching hospitals cannot be over-emphasized. Over the years, some policies affecting service delivery in the health sector has been viewed by health workers to be unfavourable to their working conditions. Employees of teaching hospitals often feel that policies are not designed to favour their work-life balance. This has made health sector workers, particularly the nurses, question the rationale behind some long work hours, poor wages and salary, work overload, poor working condition anpoor policy implementation. All these have made nurses develop strong negative attitude towards services delivered to patients, patients’ relations and management of the hospitals. Complaints on the attitude of nurses to the patients they care for is very common in hospitals, particularly in teaching hospitals. This has resulted to patients and patients’ relations’ dissatisfaction with service delivery in the hospital.
Many times issues of policy are only in theory, and not well implemented in hospitals. The policies deemed to promote the public interest target only a certain group ‘the patients’, at the negligence of teaching hospitals employees. The intent of these public policies is to protect all members of society but with focus on a select few the rest have to fight to protect themselves. Policy problem in the health sector usually comes up when a section of the sector picks up an issue and demands government action. Nursing profession is the bed rock of patient care and this puts a great demand on the nurse, who is supposed to have the heart of ’gold’ that gets better with pressure from the heat.
Several patients and their families have had to make complaints regarding the attitude of hospital staff of different categories and the poor quality of service delivery in some Nigerian tertiary hospitals. Nurses are worst hit by the complaints because of negative work attitudes associated with them as observed by patients and their relations. These attitudes include intolerance and slow response to patients’ complaints, lateness to duties and assigned jobs, violence, absenteeism, sabotage, deliberate neglect of duties, tardiness. In recent times, nurses have even come under verbal and physical attacks by patients and their relations on the accusation of insensitivity and lack of human nature required by their profession while delivering care to the patients (Mustapha, 2014). Many patients are scared stiff of their nurses because they do not want to arouse their anger with their incessant demands of emotional and physical needs. Relations of patients take turns to hang around the hospital wards since they do not trust their loved ones will get adequate care, particularly in the night as nurses are accused of sleeping.
Prof Babatunde Osotimehin, the former Minister of Health accused doctors and nurses in Nigeria hospitals of habitual negligence to duties for personal pleasures and this could worsen the healthcare delivery system in the country (Osotimehin, 2009). He further remarked that health workers in Nigeria were largely responsible for the deaths of patients across the country (Osotimehin, 2011). Therefore, the issues of nurses work attitude and its consequences as it with other health workers is known not just to patients’ relations, but higher health authorities. Furthermore, service delivery in the tertiary hospitals may not be what it should be due to some factors affecting nurses attitude, such as, unsatisfactory working conditions characterized by; short-staffing, poor salary structure, lack of consumables and supplies to work, use of obsolete medical equipment and methods, unsafe workplace and lack of motivation (Chukwuma, 2014).
The high ratio of patients to a nurse in Nigeria when compared with the WHO standard, is a major cause of concern. By WHO standards, Nigeria is not on track to meet the very low benchmark of 2.5 doctors, nurses and midwives per 1,000 people. For close to a decade and a half, the scale of nursing shortage has been termed a global crisis because the supply of nurses cannot meet the demand. The WHO recommends a nurse to a population ratio of 700, but according to the Open Journal of Nursing, 2014, Nigeria has less than 150,000 registered nurses to cater for an estimated 160 million population, giving an average nurse population ratio of 1 to 1,066 people. This creates work overload that may lead to easy irritability and poor attitude towards patients. According to Pearsall (2012), sleep deprivation due to long hours shift without rest or sleep contributes to officers’ irritability with the public and inability to maintain calm in situations due to diminishing attentiveness; it also impairs physical and cognitive abilities. This study therefore looks at how policy affects nurses work attitude and patients satisfaction of service delivery in Nigerian teaching hospitals.
1.3 Objective of the Study
The main objective of the study was to investigate the effect of policy on nurses’ work attitude and patient satisfaction with service delivery in Nigerian teaching hospitals. The specific objectives are to:
1 investigate the effect of policy on nurses’ work attitude in Nigerian teaching
hospitals;
2 assess the effect of nurses work attitude on service delivery in Nigerian teaching
hospitals;
3 examine the effect of nurses’ work attitude on patients’ satisfaction in Nigerian
teaching hospitals and
4 determine patients’ satisfaction with service delivery of Nigerian teaching
hospitals.
1.4 Research Questions
- What are the effects of policy on nurses’ work attitude in Nigerian teaching
hospitals?
- How does nurses’ work attitude affect service delivery in Nigerian teaching
hospitals?
- Does the nurses’ work attitude affect patients’ satisfaction in Nigerian teaching
hospitals?
- Are patients satisfied with the service delivery in Nigerian teaching hospitals?
1.5 Hypotheses
H01: Policy does not have a significant effect on Nurses’ work attitude in
Nigerian teaching hospitals.
H1: Policy does have a significant effect on Nurses’ work attitude in Nigerian
teaching hospitals.
H02: Nurses’ work attitude does not have a significant effect on service
delivery in Nigerian teaching hospitals.
H1: Nurses’ work attitude does have a significant effect on service delivery in
Nigerian teaching hospitals
H03: Nurses’ work attitude does not have a significant effect on patient
satisfaction in Nigerian teaching hospitals.
H1: Nurses’ work attitude do have a significant effect on patient satisfaction in
Nigerian teaching hospitals
H04: Service delivery does not have a significant effect on patient satisfaction
in Nigerian teaching hospitals.
H1: Service delivery does have a significant effect on patient satisfaction in
Nigerian teaching hospitals
1.6 Significance of the Study
The theorization of health policy is very important for understanding as well as a guide for actions. Therefore, this study hopes to contribute to the theoretical underpinning of health research and service delivery, as well as public policy analysts both in the private and public sectors.
The findings of this study may be useful in the improvement, setting of standards and encouragement of debates on policy formulation that could lead to changes in the public awareness of the challenges facing the health care giver, particularly the nurse. More specifically, the researcher hopes there would be a policy implication of the findings from the study at the institutional level of the studied population (LUTH and BUTH), while providing a further basis for more studies in this area.
1.7 Scope of the Study
This study was carried out in two Nigerian teaching hospitals– Lagos University Teaching Hospital, Lagos state, a public or Federal Government teaching hospital and Babcock University Teaching Hospital, Ogun state, a private teaching hospital under the Babcock University owned by the Seventh Day Adventist Church. The targeted respondents for this study included registered nurses presently working in both hospitals and presently registered out-patients and in-patients of the hospitals. The study also covered some patients, patients’ relations and principal management officers of the two hospitals.
1.8 Operational Definition of Terms
Attitude: In this study, attitude is the way the nurses are seen to behave to their patients in the hospitals.
Inpatient: In this study, this refers to the registered patients of the hospitals admitted to the wards in order to receive care and treatment for their illnesses.
Nurses: This refers to professionally trained persons assigned the responsibility of taking care of the hospitals’ patients on the wards and the outpatient clinics
Outpatient: In this study, out patients refer to those registered to receive specialized care on outpatient basis. Their illnesses are not serious enough to admit them to the ward.
Tertiary Health Institution: In this study, the tertiary institution represents LUTH and BUTH that provide health care to patients referred to them for specialized health care.
Policy: In this study this refers to the actions or inactions by the hospitals to achieve their organizational goals.
Service Delivery: This is the interaction between the nurses and the patient whereby the nurses offer care and services to the patients supposedly according to the policies of the hospital environment, motivation, performance and satisfaction
Work Attitude: In this study, it means the predisposition or tendency of the nurses to respond positively or negatively towards the patients of the hospitals. It is also the nurses’ responses to challenges, incentives and rewards. In other words, their attitude may be strongly influenced by situational constraints.
Satisfaction: This in this study refers to the contentment of patients when they receive good treatment from the hospital.
1.9 Chapter Outlay
A comprehensive study of some policies likely to affect the attitude of nurses towards various matters that impinge on patients’ satisfaction and service delivery, comprise the composite meaning of this thesis.
Chapter 1 is an introduction containing a commentary on the choice of the subject matter. The hypotheses for the inquiry are stated and the research design and method of study are also described. The aim and significance of the study are laid out with brief information of the hospitals under study. Chapter 2 which is the literature review traces the evolution and subsequent development of the health services in general and an analysis of previous researches on attitudes of nurses on service delivery. It also discusses the theories of motivation and organizational behavior in relation to the topic under study. Chapter 3 describes the Methodology of the thesis and gives a step by step direction of the research design, data collection and how the study intends to analyze the relevant data it gathers in the course of the study. Chapter 4 is the research findings which were analyzed alongside the initial hypotheses and assumptions, and also in the context of relevant theories that have featured in the previous chapters. Finally, Chapter 5 provides a summary and conclusion of the thesis, as well as highlighting suggestions and recommendations of the researcher.
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