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.
CHAPTER
ONE
INTRODUCTION
1.1
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 becausehealth 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.
1.2
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
1.
What
are the effects of policy on nurses’ work attitude in Nigerian teaching
hospitals?
2. How
does nurses’ work attitude affect service delivery in Nigerian teaching
hospitals?
3. Does
the nurses’ work attitude affect patients’ satisfaction in Nigerian teaching
hospitals?
4. 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
veryimportant 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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