Many of the developing nations worldwide have similar problems that are a challenge to the success of the efficiency of their healthcare systems (Elkhammas & Singh, 2010, p. 149). With particular concern is Africa has 25% of the global disease burden with only 2% of the total healthcare workers globally work in Africa which has less than 1% of global health funding (World Health Organization (WHO, 2014). That already is a manifestation of struggling healthcare systems in which health workers have work in developing nations
In the USA it has been established that when health personnel are over-worked it results in sub-optimal care being given to patients by healthcare workers (Janicijevik, Seke, & Filipovic, 2013). This problem is made worse by the frequent brain drain that favours the developed countries, making developing countries fail to retain healthcare workers they need resulting in low doctor-patient ratios (Elkhammas & Singh, 2010; Musau, Al-Sadat, & Gerei, 2010). The low doctor-patient ratio in many African countries is worsened by unequal distribution of doctors, more sparsely in the countryside (Elkhammas & Singh, 2010, p. 149). This simply exacerbates the pressure health care facilities and healthcare workers are having in terms of facilities, resources and personnel in Africa .
Migration of health workers from Africa is costing African countries huge losses (Mills et al., 2011). The reasons healthcare workers migrate from poor developing countries is based on many factors. In the USA it was noted that under-staffing healthcare facilities had a high correlation with inpatient mortality. This supports the view that under-staffing healthcare facilities increases their work load of healthcare givers and the low doctor-patient ratios in Africa are extremely unfavourable for efficient delivery of services. Kenya has 49 nurses, 7 doctors and 8 clinical officers per every 100,000 peopl . This simply means that understaffing hospitals with doctors is a predictor to poor health outcomes in the treatment of patients and leads to high patient turnover (Needleman et al., 2011). From this statistics it implies Kenya has an approximate population of 25,600 healthcare workforce for a population over 42 million people currently. This translates to approximately one healthcare worker (regardless of whether it is a doctor, clinical officer of nurse) for every 1,641 people. This implication means the healthcare workers have a very high workload rate that may impact negatively on their output
This indicates the doctors and nurses who remain in a very large extent work in very challenging environments. Many of them quit government employment for better paying opportunities in the private sector or seek employment abroad. This shows that some of the health workers are stretched beyond their endurance limit to the extent they lose resilience (Rajan-Rankin, 2013) . This loss of resilience is a coping strategy, and an indicator of doctors and nurses feeling frustrated by the work environment they operate. Medical work may lead to psychological, physical and mental stress on a healthcare worker, and this will have a great influence on their productivity in terms of output of quality service (Govender, Mutunzi, & Okonta, 2012)
Healthcare workers need to have good customer relations and very empathetic to effectively deal with patients. More often than not they also operate in a continuous atmosphere of inadequate resources in many African countries. Thus, despite the shortcomings in resource availability, research shows that an empathetic and caring health worker generate more customer satisfaction in the patient (Pollak et al., 2011). Many patients in Kenya have reservations of the customer care attributes healthcare workers especially nurses (Katira, 2014). A patient who rates his /her experience highly with a doctor is likely to make a repeat visit to a health facility they have used before. Patient satisfaction can be an indicator of an effective healthcare workforce despite lacking enough facilities and resources.
The attitude of some healthcare workers has made them be pivotal in attracting patients to the health facilities in which they are situated. The idea of medical professional being a calling can be used to determine how healthcare workers perceive their roles in the community. It should be noted that when one looks at illness, it is a manifestation of two distinct worlds of realities between the doctor and the patient. In this relationship, how the health workers communicate with patients is a marker of the nature of communication they undertake with each other. Therefore the effectiveness of the communication strategies employed by the patient and the healthcare giver shapes their doctor/nurse patient relationship (Jacobson, 2007).
The design and medical resources available in healthcare facilities have been known to motivate workers to greater productivity. Over time scholars have realized that the way the physical environment has been constructed as work station, it will ultimately end up influencing employee performance (Carr, 2014). In this construction of the physical environment of a healthcare facility, health care workers may be appealed to develop better therapeutic nurse-patient relationship and hence create a good rapport with the each other (Pullen & Mathias, 2010). This is another significant marker that can point at the general attitudes of the healthcare market area and their utilization of the facilities.
However, availability of resources is scarce in many African countries. The World Health Organization notes that Africa accounts for an incredible 25% burden of infectious diseases globally yet it only has less than 2% of the global share of doctors (WHO, 2014). This provides the evidence of the way healthcare workers in Africa have a huge workload.
1.2 Statement of the Problem
It has been noted that Africa has a very high disease burden which is made worse by the high rates of poverty and presence of a “vector-favourable climate” (Denis et al., 2014). Access to treatment is problematic yet it has been observed that the few who manage to access healthcare facilities make return visits. Secondly, while many research studies have focused on efficiency of healthcare workers and the availability of resources, so far no literature surveyed shows of any study being conducted that have demonstrated the significance of health seeking behaviour of patients and how they are influenced to seek healthcare from the same facilities that they deem them inadequately staffed, with non-empathetic and rude medical staff in the perceptions of patients.
Third, with low motivation that healthcare workers get in Kenya, selected literature surveyed clearly shows there is a contradiction that needs to be investigated. While many of the rural healthcare facilities suffer the vagary of insufficient resources, such as medication and poor facilities, it is presumed that the rural poor use the facilities that are understaffed because of poverty. There is need to determine how the doctor-patient relationship in such an environment influences return visits to the same hospitals. This is at variance with consumer buying behaviours theories that posit excellent customer care and positive experience lead to repeat sales (repeat patient visits in the case of utilization of health care facilities)
Healthcare workers in public health facilities have high workload burden which affects their productivity in terms of service delivery to patients in Kerugoya Subcounty
1.3.2 Objectives of the Study
1.3.3 General Objectives
Evaluating Workload Burden and influence of healthcare workers in selected public health facilities facilities in Kirinyaga County of Central Kenya Region
1.4.2 Specific Objectives
- To determine the number of doctors, clinical officers and nurses in public healthcare facilities in Kirinyaga County
- To determine the number of patients they handle per month for a one calendar year period in public healthcare facilities in Kirinyaga County
- To analyze the workload burden of healthcare workers in terms of number of patients handled and the type of service offered in the one year period in public healthcare facilities in Kirinyaga County
- Establish the reasons why healthcare workers get satisfied with their jobs in the face of the challenges they encounter
- Establish the coping strategies healthcare workers use in overcoming high workload stress and de-motivation
1.5 Research Questions
- What is the total population count of healthcare workers in public health facilities in Kirinyaga County?
- What is the total number of patients handled by the healthcare workers per month over a one year period in in public healthcare facilities in Kirinyaga County?
- What leads to healthcare workers being satisfied with their jobs in the face of challenges they encounter in public healthcare facilities in Kirinyaga County?
- Why do healthcare workers get satisfied with their jobs in the face of the challenges they encounter in public healthcare facilities in Kirinyaga County
- What are the coping strategies the healthcare workers use to overcome high workload stress and de-motivation in public healthcare facilities in Kirinyaga County
1.6 Assumptions of the Study
- The low doctor-patient ratio in Kirinyaga County increases workload and stress for healthcare workers.
- There is a monthly variation in terms of workload burden and stress level for healthcare workers in Kirinyaga County in any calendar period
- There is a monthly variation in terms of workload burden and stress level for healthcare workers in Kirinyaga County in the a one calendar year period
- Workload burden and stress level is affected by the number of patients handled and type of service given by healthcare workers in Kirinyaga County
- Healthcare workers derive some degree of job satisfaction despite their high workload burdens in Kirinyaga County
Justification of the Study
The study seeks to establish the underlying reasons why healthcare workers work in poor work environments and poor remuneration and still remain in their work stations and carrying at their duties. The research will provide information that will shape the policy decisions that govern the relationship between healthcare workers and patients.
By doing so, patients are likely to benefit because what compels the healthcare workers to serve them will be understood against the background of their grievances. This will lead to identifying the factors that make healthcare workers work when in extreme variance with their employer lastly, the information gathered will help the County Government of Kirinyaga and the National government to design better policies that actually promote the factors that motivate healthcare workers for the benefit of the general public
2.0 LITERATURE REVIEW
2.1 Theoretical Framework
The theoretical framework that will guide this research is based on Herzberg’s Two Factor which posits that there are many factors in the workplace environment that create job job dissatisfaction in employees. While a lot has been done to study how factors of job dissatisfaction affect employees, available literature indicates nothing has been done to demonstrate the way healthcare workers in developing countries overcome dissatisfiers in their work environment in a situation where the factors that dissatisfy them are ever present yet they do not leave their jobs. This research will make a unique attempt in evaluating the job dissatisfies on non-exit of health workers who are not having hygiene factors of motivation realized in the jobs
There is need to understand the push and pull factors which make health workers remain in a public health facility or move to the private sector or even seek greener pastures abroad especially in the developed world. It is estimated that more than 30% of healthcare personnel who were born and trained in sub-Saharan Africa emigrated to the developed countries (Poppe et al., 2014). While global statistics point out to what is happening concerning doctors migrating from sub-Saharan Africa, a survey of selected literature focus on why doctors leave but not what makes them remain behind despite the poor working conditions and de-motivation they encounter.
Kenya has an abject shortage of doctors with only 2,300 doctors serving public health facilities which are a far cry of the WHO recommended standards of 1 doctor for every 1,000 people . The pressure on the doctors who remain in public services is therefore big and employee burnouts are associated with this. It is a matter of conjecture on how healthcare workers manage to discharge their duties and achieve relative high success rates in treating patients regardless of how they handle them. In the doctor-patient relationship, the doctor is usually seen as the one who can help the sick regain good health as the knowledgeable other in the relationship. This exposes a gap in knowledge that needs to be filled
2.2 Workload as a predictor of Job Satisfaction
Based on Herzeberg’s Two Factor theory of motivation, it should be noted that many Kenyan health care professional have quit from the public sector employment. Using Herzeberg’s Two Factor Theory, one needs to discover the motivationa factors that make healthcare workers remain in the public healthcare facilities Kinfu et al., 2009). Healthcare workers are an important component of the healthcare system . The achievements of workers through motivation needs to be evaluated again to determine to what level are the de-satisfiers that make employees shun the jobs, or exit the profession influence their decisions. Contary to what many researchers do, using Herzeberg’s Two Factor Theory to establish conditions that either motivate employees or make them dissatisfied, this study seeks to use the theory in determining what makes them remain in their jobs and work stations despite being de-motivated. This is a gap in knowledge that begs attention.
2.3 Patient Use of Public Healthcare Facilities
Healthcare facilities are used by patients based on their consumer buying behaviour. The theory of consumer buying behaviour looks at the factors and steps individuals under before they came to a decision to buy a product. The consumer buying behaviour will allow the research to determine when, where, how and what the buyer wants. In the context of this study, consumer buying behaviour should be construed as the way patients and other relevant others in a pateint’s come to the decision to use the hospital facilities in solving their health problems.
The use of healthcare facilities is functionally an outcome of the decision to seek healthcare and being affordable for the patient. The patients who have a bad consumer buying behaviour experience of healthcare facilities in the way they have utilized the facilities will not go back to the centres. However, despite the usual explanation based on poverty and inability to access better healthcare facilities in rural areas, this research looks at what promotes health seeking behaviours of patients to make repeat visits to facilities they consider unhelpful. There is a missing link between customer dissatisfaction and repeat purchase which is exhibited by many rural folks in Kirinyaga County
2.4 Coping Strategies and Motivation of Health Care Workers
In looking at the situation of healthcare workers in Kenya, the issues that de-motivate them are inherently intertwined with their work environment. Secondly, a social expectation that healthcare workers should live upto a certain standard of life compels them to seek extra employment in other private facilities. The issue that needs to be understood the coping strategies are a predictor that the pay and work conditions are not good. This psychologically affects the way doctors, nurses and clinical officers relate with patients. Based on expectancy, what the healthcare workers wants is at variance with what the patient needs. When the healthcare workers resort to industrial action which contravenes their Hippocratic oath, patients in their health-seeking behaviours have been reported to go even to the healthcare workers homes to seek help. What motivates the healthcare workers to assist the patients extant to the hospital environment still remains unknown. Research studies so far do not provide clue of healthcare workers being highly underpaid, in resource-deficit working environments remaining their and serving patients fully or partially
3.0 MATERIALS AND METHODS
3.1 Description of Study Site
The study will be conducted in Kirinyaga County in the Central Region of Kenya. The county has a population of xyz people as per the 2009 National census. Kerugoya has xyz healthcare facilities serving a population of xyz number of people, with X, Y and Z numbers of doctors, clinical officers and nurses respectively
3.2 Research Design
The study will use descriptive cross-sectional survey design in collecting quantitative and qualitative data from the sample population
3.3 Targeted Study Population
The target population will be the doctors, nurses, clinicians in addition to the patients who make a repeat visit to the selected facilities within a one year period.
3.4 Sample Determination, Selection and Sampling Design
The sample size will be determined by using the sample size determination table proposed by Glenn Israel which was developed from Cochran’s formula for determine the appropriate sample size in regard to different confidence levels required in a study (Israel, 2013, p. 3)
Sample selection will be done in two ways. For healthcare workers stratified proportionate sampling will be used. Using Israel’s table, the total number of healthcare workers will be determined and each group allotted proportionately in the sample population
The population of patients will be selected on a simple systematic random selection. The total population of the number of patients handled the previous year will be assumed to be equal to the current year and that will guide the sample size determination as given by Glenn Israel (2013).
3.5 Data Collection Instruments
The data collection instruments will be the questionnaire and the use of the interview schedule. The high literacy levels of healthcare workers will allow them to fill the questionnaires of their own.
For the patients, some are expected to be illiterate and use of the interview schedules will be appropriate. In some cases, use of focused group discussions will be used to collect data
3.6 Data Collection Procedures
The researcher and the research assistants will introduce themselves to the respondents and explain the aim of the research. Those who agree to be respondents based on informed consent will either be included in a Focussed Group Discussion (FGD) or have the interview schedule administered to them.
3.7 Data Analysis
Data will be analysed using statistical procedures of mean, averages, percentile, quartile and simple aggregation. The use of inferential statistical procedures of Pearson’s r-Correlation Coefficient will be used to infer the level of linear correlation between the coping strategies employed at different workload burden and stress level to determine if there is any relationship and the significance of that relationship. Contextual analysis will be used to analyse the qualitative data collected.
The findings will be summarized in a report and presented with charts and tables in a discussion of the findings of the research
3.8 Ethical Considerations
During the data collection process, the research team will ensure the rights and freedom of the respondents is highly respected by safeguarding their privacy and confidentiality during the data collection process and thereafter in the data analysis and compilation of the report. At no point in time during the research process will this be violated and the respondents will be assured of this in seeking their informed consent to be participants in the study
Informed consent will be obtained from respondents without misrepresentation of facts or use of fraud. Participants will be required to s form indicating the were enlisted only after agreeing to be respondents. Children will not be interviewed due to ethical concerns, instead their parents will be interviewed
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Herzberg’s Theory of Motivation”
By Julio Warner Loiseau,