Healthcare Workers' Perceptions towards Hospital
Leadership and Institutional Structure in Chiro and
Gelemso Hospitals, West Hararghe Zone, East
Ethiopia
By
Ayalew Aklilu
Second Draft Thesis to Be Submitted to The Department of Health Services
Management College of Public Health and Medical Sciences, Jimma University in
Partial Fulfillment of the Requirements for the Degree of Masters of Public Health
in Health Service Management
August, 2012
Jimma University
i
Healthcare Workers' Perceptions towards Hospital
Leadership and Institutional Structure in Chiro and
Gelemso Hospitals, West Hararghe Zone, East
Ethiopia
By
Ayalew Aklilu
Advisors:
Shimeles Ololo (BSc.PH, MPH)
Berhane Megersa (BSc.PH, MSc)
August, 2012
Jimma University
ii
Abstract
Background: The perception of health worker have an enormous impact for the successful
implementation of health sector reform thus identifying factors that affect their perception
have a significant importance for amending some of the organizational structure and
advancing strategies to achieve organizational goals. However, what is happening in
developing country like Ethiopia is, contrary to this and identifying factors that affects
perception of health workers have eminent roles for mangers in order to improve and create a
motivated health care provider.
Objective: The ultimate objective of this study is to investigate perception of healthcare
workers towards the institutional structure and leadership.
Methods: A cross sectional quantitative study was undertaken to assess the perception of
health workers towards their institutional structure and leadership in Chiro and Gelemso
hospitals, West Hararghe zone, East Ethiopia, from May 15 to 30, 2012. A total of 204 health
workers agreed to participate in the study out of 218 yielding a response rate of 93.6%. Self
administered structured questionnaires were used to collect data. The instrument had good
internal consistency with Cronbach’s alpha =0.927 and 0.906 respectively. Data were entered
and analyzed using SPSS Version 16. Multiple linear regressions were applied once after the
assumptions checked and adjusted R2
were used to explain the variation in the outcome by
independent variables. The issue of ethical clearance and confidentiality were maintained.
Results: The overall perception of institutional structure and leadership in this study were
37.2% and 31.6% respectively. About 59.3% of the respondents perceived that as their
Hospital did not give enough emphasis on the quality of service it provides and a majority of
the health workers (69.6%) perceived that there were inadequate facilities, 59.8 % of the
respondents perceived that their hospitals did not have adequate staff in all key positions and
only 32.8% of the respondents perceived that there is a formal problem solving in the
hospital.
Conclusion and Recommendation: The overall perception of health workers towards
institutional structure and leadership is very low. In order to improve this Management body
of the two hospitals should have to promote health workers based on their performance and
strength and maintain their Facilities and equipment.
.
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Acknowledgement
I would like to present my jovial salutation to my advisors Mr. Shimeles Ololo and Ms.
Berhane Megersa for their momentous support during the course of proposal development
and final thesis preparation. I am also indebted to Ato Reta Bekele, who is the Managing
Director of RVUC for his unlimited support. My special thank go to Mr. Shimeles Hussein
for the initial motivation to start this journey.
I am most grateful to my family, to my mom and dad, I want reminds you, as you are always
so special to me.
I would like to extend my heartfelt gratitude to the staff Chiro and Gelemso Hospitals,
Managers of both hospitals and Administrators of West Hararghe Zonal Health department
for their magnificent cooperation.
May this work bring glory to God, my Strength and my Redeemer is through Jesus Christ. I
owe my life to Him.
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Table of content
Abstract ...................................................................................................................................... ii
Acknowledgement ................................................................................................................... iii
Table of content ........................................................................................................................ iv
List of Tables ............................................................................................................................ vi
List of Figures .......................................................................................................................... vii
Acronyms ............................................................................................................................... viii
Chapter 1: Introduction .............................................................................................................. 1
1.1. Background ................................................................................................................. 1
1.2. Statement of the problem ............................................................................................ 2
Chapter 2: Literature Review ..................................................................................................... 4
Conceptual Frame work ............................................................................................................. 6
Chapter 3: Significance of the study ...................................................................................... 8
Chapter 4: Objectives of the study ......................................................................................... 9
General Objective ................................................................................................................. 9
Specific Objective .................................................................................................................. 9
Chapter 5: Methods and Materials ........................................................................................... 10
5.1 Study area and period ................................................................................................ 10
5.2 Study design .............................................................................................................. 10
5.3 Population.................................................................................................................. 10
5.3.1 Source population and study population ............................................................ 10
5.3.2 Inclusion and Exclusion Criteria ........................................................................ 10
5.4 Sample size and sampling techniques ....................................................................... 11
5.5 Data collection process and measurements ............................................................... 11
5.5.1 Development of data collection tools ................................................................ 11
5.5.2 Personnel recruitment and training .................................................................... 11
5.5.3 Data collection procedures ................................................................................. 11
5.5.4 Study Variables .................................................................................................. 12
5.6 Operational definition ............................................................................................... 13
5.7 Data analysis ............................................................................................................. 15
5.8 Data quality management .......................................................................................... 16
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5.9 Ethical Consideration ................................................................................................ 16
5.10 Limitation ion of the study ........................................................................................ 17
5.11 Dissemination plan .................................................................................................... 17
Chapter Six: Results ................................................................................................................. 17
Chapter Seven: Discussion ...................................................................................................... 30
Chapter Eight: Conclusion and Recommendation ................................................................... 33
8.1. Conclusion ..................................................................................................................... 33
8.2. Recommendation ........................................................................................................... 34
References ................................................................................................................................ 35
ANNEXES: I ........................................................................................................................... 39
Questionnaire ........................................................................................................................... 39
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List of Tables
1. Table1: Age and service year of health workers of Chiro and Gelemso hospitals, east
Ethiopia, 2012
2. Table 2: Other Basic Characteristics of health workers of Chiro and Gelemso hospitals,
east Ethiopia, 2012
3. Table 3: Health worker perception towards organizational climate of Chiro and Gelemso
Hospitals, east Ethiopia, 2012
4. Table 4: Perception of health workers towards infrastructure of Chiro and Gelemso
Hospitals, east Ethiopia, 2012
5. Table 5: Perception of health workers towards human resources of Chiro and Gelemso
Hospitals, east Ethiopia, 2012
6. Table 6: Perception of health workers towards Leadership of Chiro and Gelemso
Hospitals, east Ethiopia, 2012
7. Table 7: Variation of the outcome variable explained by predictors, east Ethiopia, 2012
8. Table 8: predictors of perception of health workers towards institutional structure , east
Ethiopia, 2012
9. Table 9: predictors of perception of health workers towards institutional leadership, east
Ethiopia, 2012
vii
List of Figures
1. Figure 1: Conceptual framework using variables in health worker perceptions towards
Leadership and Organizational Structure: a case of Chiro and Gelemso Hospitals, 2012.
2. Fig.2: A Histogram that show the distribution dependent variable against the predictors
3. Fig.3: A P-P that show the distribution dependent variable against the predictors
4. Fig. 4: A Histogram that show the distribution outcome variable against the predictor
5. Fig.5: A P-P that show the distribution dependent variable against the predictor
viii
Acronyms
1. AIDS - Acquired immune-deficiency syndrome
2. AOR: Adjusted Odds Ratio
3. FMOH - Federal Ministry of health
4. HIV- Human immune-deficiency virus
5. HSD- Health sector development
6. HSR- Health sector reform
7. HW – Health worker
8. HWP- Health worker perception
9. LB - Leadership Behavior
10. MDGs- Millennium development goals
11. OR: Odds Ratio
12. RHB- Regional Health Bureau
13. RVUC – Rift Valley University College
14. WHO- World Health organization
1
Chapter 1: Introduction
1.1. Background
Until recently, human resources have been overlooked during the course of health sector reforms
(1, 2). A number of factors ranging from the individual to national level operate together to
influence how health workers take up interventions to improve their work practices. Often this
influence works through the local personal, educational, professional, community, or institutional
environment in which work takes place or the social, cultural, economic, and political
environments more generally. At the individual health worker level, many of these influences are
understood to affect a worker's perception to act in desired ways. Thus, understanding those
factors that influence worker perception is important when trying to explain why interventions
that rely on changing worker behavior succeed or fail (3).
Today, African health systems are experiencing one of the greatest staff shortages and clinical
staff is currently faced weak institutional frameworks and distortive incentive structures,
ineffective management practices and adverse work environments at systemic and organizational
level, resulting in an overburdened health workforce (4).
Employees desire to feel that they are a part of something substantial. When this occurs,
employees find enthusiasm for their future and that of their organization. One method of
achieving this is through a united vision where employees are empowered by their leaders to
work toward the vision and within a value system that is congruent with their own (5).
However, worker perception and its influence on changing clinical practices of health workers in
low-income settings is rarely explored as a major factor that may mediate or modify the effects
of interventions . More usually, studies of health worker's perception explore determinants of
perception by examining the subjective feeling and attitude of health workers either to
understand effects of health sector reforms on worker performance or influences of
performance management on worker perception (6).
2
1.2. Statement of the problem
During the past 15 years in sub-Saharan Africa, many countries have been undergoing health
sector and civil service reforms that directly influence the design of the public health care system
and the use of human resources (7). For more than a decade, Ethiopia has been implementing
health sector reform which is now in its fourth phase of strategic planning but studies revealed
that the ability of any institution attract, retain and maintain competent and satisfied staff into its
employment is very challenging (8). And to strengthen this idea, the World development report
2004 state, without improvements to the human resources situation, the health-related
Millennium Development Goals cannot be achieved (9).
Other study also emphasizes the importance and impact of employee perception on turnover
intent as an area which should not be neglected (10).A study in the field of organization had
been done on employees’ attitude and behavior on organization effectiveness and revealed as
various factors affect employee perception, such as the job characteristic, the leadership and
organizational structure (11).
In a study which was conducted in 499 health workers of Nigeria four hospital revealed that
about 64% of the respondents disagreed or strongly disagreed that their hospitals had adequate
staff in all key positions for health sector reform, 53% of the respondents disagreed or strongly
disagreed that compensation is adequate for attracting, 57% of the respondents agreed or strongly
agreed that opportunities exist for staff professional development and on-the-job training and
keeping key staff, 69.9% perceived that there were inadequate facilities and 39.5% line of
reporting and authority are clear (12).
Parallel to this, a study of 551 health care workers perception in Ghana in January 2002, reported
that 75% mentioned lack of essential equipment, tools and supplies as a workplace issue
affecting staff performance and 94% mentioned low salary as a workplace obstacle affecting
staff performance (13).
Another study in klang valley, Malysia showed that perception of health workers was influenced
by age that older employees have favorable perception towards organizational culture. In
3
addition to this, Jobs position, education and income also affect the perception of health workers
(14).
Most study suggested that, increasing salaries and benefits, better working and living conditions,
management and supervision, career advancement and training and keeping staff healthy are
significant to keep staff and to have favorable perception. But, According to motivational
theorists such as Herzberg, increasing salaries, providing support for staff, and good health and
safety at work are not motivators and they do not enhance job satisfaction or positive
environment.
However, what is happening in developing country is, contrary to this. There is poor level of
health worker perception, which has a negative impact on the performance of individual health
workers, facilities and the health system as a whole. Moreover, it adds to the push factors for
migration of health workers, both from rural areas to the cities and out of the country (15, 16).
So in our country as to my knowledge there is no published article which clear describe the level
of health workers perception and factor that affect it, though Ethiopia is among under developed
country by which high staff attrition is very high.
4
Chapter 2: Literature Review
Health sector reform (HSR) is one of the topical issues on the policy agenda of many developed
and developing countries worldwide. A research that was conducted in Nigeria four hospitals
shown that, as the overall perception of institutional structure for health sector reform was 52.5%
(12).
Institutional structure, also called institutional formation is defined as the components and
resources that an institution has to deliver its services and generate external support. It is the
embodiment of purpose of an institution. It is important because it should reflect and support the
vision, mission, values, goals and strategy of the institution. It clearly defines and differentiates
roles and functions in the institution, untangles lines of communication and accountability, and
ensures that decision-making procedures are transparent and functional. The institutional
structure is put in place to protect, support and enable the chosen vision, strategy and culture of
the institution. The structure adopted in any institution will depend on the objectives of the
institution, its environment and context, including technology and size (12).
Several countries in Africa have embarked on health reform, but most research has focused on
the impact of reforms on recipients, particularly vulnerable groups. Very little has been written
on the impact on health worker motivation. The health sector is labor intensive and the success
of the reforms depends on, among other things, the behavior of those implementing the policies
on the ground. Research in developed countries has shown, for example, that 80% of health costs
in hospitals are a result of doctors’ diagnosis and therapy patterns. Health workers’ motivation,
manifested in their behavior in the work place, greatly affects the outcome of health reforms
(17). Health systems cannot function without trained health workers, yet until recently
researchers and policymakers paid relatively give little attention to their role in developing
countries (18).
An understanding of the perceptions of healthcare professionals and managers of the institutional
structure of their respective hospitals and its ability to facilitate the fulfillment of the HSR
objectives is important due to the central roles played by the staff members in promoting and
sustaining the changes associated with a health sector reform (HSR). There were reports of failed
HSR even in developed countries such as the United States of America during the Bill Clinton
administration due to the opposition of major stakeholders like the medical professionals (12).
5
Research reports along this line have indicated that workers with negative perceptions of safety
climate (e.g., high workload, work pressure) tend to engage in unsafe acts, which in turn
increases their susceptibility to accidents (19, 20). Similarly, workers who have indicated job
insecurity, anxiety and stress, have exhibited a drop in safety motivation (21) and recorded a
relatively higher accident involvement rate (22, 23, 24). In contrast, workers with positive
perceptions regarding safety climate have expressed greater job satisfaction (25) and registered
fewer accidents (26).
According to Shore L., workers with higher perceptions regarding management’s contributions,
support and concern for their wellbeing have a greater job satisfaction (27). Additional research
revealed that, organizational support will affect differently workers’ perceptions (28).
A Study examining health worker motivation in two hospitals in the Hashemite Kingdom of
Jordan on 264 health workers disclosed that, respondents reported generally positive perceptions
of hospital characteristics; only “job and career opportunities” fell far below a neutral rating.
Overall, the mean responses of different respondent groups (i.e., worker, supervisor, and
manager) were similar, although workers showed a non-significant tendency to report lower
(more negative) responses than supervisors and managers. Only the perception of “management
openness” showed a significant difference among the various levels, with workers disagreeing
with this characterization of management, while supervisors agreed with the statement, and
managers agreed even more strongly that they were open to suggestions from workers.
Comments from respondents indicated that some of this unresponsiveness may be due to MOH
regulations that are beyond the purview of hospital management. There are Statistical
interactions between hospital and types of worker were found for pride/reputation and
management openness. Other workers (allied health professionals and service/administrative
workers) at Al-Ramtha hospital were most likely to respond positively on pride/reputation, while
nursing staff at Al-Ramtha were more likely to have negatively perceptions on management
openness than others at Al-Ramtha, or at Al-Basheer (29).
6
Conceptual Frame work
Figure 1: Conceptual framework using variables in health worker perceptions towards
Leadership and Organizational Structure: a case of Chiro and Gelemso Hospitals, 2012.
As work motivation is a transactional process, a worker’s motivation is contingent upon the
organizational context in which the worker is situated. The organization must provide
complementary inputs (such as drugs and medical supplies), as well as clear, efficient systems.
Organizational structures and processes will affect workers’ experience of outcomes and the
nature of feedback that a worker receives from colleagues and supervisors within the health
system. Human resource management systems affect workers’ capability and their perception of
that capability, through such mechanisms as training, supervision, and more concrete incentives
such as remuneration, promotion, and performance review processes (30).
7
In addition to this, Good leadership is important for the success of any organization. In a
healthcare organization, good leadership is more than just important—it is absolutely critical to
the organization’s success (31). This may entail, as the issue of leadership determines worker
perception for their organization.
8
Chapter 3: Significance of the study
One of the critical challenges in today’s dynamic and turbulent organizations is to retain
capable workforce for the maintenance and improvement of firm’s and Research has shown
employee commitment is an indicator of effective relationship among boss, team members, and
subordinates. It is also identified that employee perception for their organization influences
critical organizational outcomes such as job performance, employee commitment, job
satisfaction, teamwork, and turnover (32). And other study had shown that, when an employee
perceives that he is treated fairly, it is logical that he consequently feels satisfied with the job
(14).
Since, there is no study done on this issue, knowing the level of perception and factor that affect
it has an eminent role. For administrators of the two hospitals, help to amend their organizational
structure, to advance strategies and to be aware and take a decisive measure to improves
perception of health worker that helps to build a satisfied and motivated health worker.
The findings of this study will also gives as a way for West Hararghe zonal health department to
realize factors that affect the perception of health worker and enable them to made scientific
based judgment. In addition to this it has a great benefit researchers, students or policy maker to
utilize as base line information.
9
Chapter 4: Objectives of the study
General Objective
To assess the perception of healthcare professionals towards the institutional structure
and Leadership of Chiro and Gelemso hospitals, 2012
Specific Objective
To assess perception of health worker towards Institutional structure.
To measure health worker perception towards the Institutional leadership.
To determine factors that affect perception of health worker towards their Institutional
structure.
To determine factors that affect perception of health worker towards the organizational
leadership.
10
Chapter 5: Methods and Materials
5.1 Study area and period
The study was conducted in Chiro and Gelemso Hospitals from April 15 – 30, 2012. Chiro
Hospital is located at Chiro Town, West Hararghe zone, 320 km away from Addis Ababa in the
east direction on the main high way to Harar and Dire Dawa Cities while Gelmso Hospital is
situated in west Hararghe zone, but in Gelemso town. The town is found 52 km away in the
southwest direction from Chiro. The hospitals have different units and render services
approximately 2,300,000 population of the zone and are the only hospitals found in the zone.
Chiro and Gelemso Hospitals have 107and 113 health workers respectively.
5.2 Study design
Cross-sectional study designs using quantitative method were employed.
5.3 Population
5.3.1 Source population and study population
All health workers of Chiro and Gelemso Hospitals who were at work during the study period
were considered both source and study populations for this study.
5.3.2 Inclusion and Exclusion Criteria
Inclusion Criteria:
Health workers who served for more than 6 months in the hospitals.
Exclusion Criteria:
Health worker who were ill and unable to respond during the study period
Health worker on maternal and annual leave
Employee of NGO but who serves in hospital
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5.4 Sample size and sampling techniques
Since, the study populations are small; the study was conducted on all health workers who fulfill
the inclusion criteria.
5.5 Data collection process and measurements
5.5.1 Development of data collection tools
Data collection tool development was mainly based on the issues the study wish to address. The
questioner had two parts and prepared in English version. The first part of the questioner was
aimed to comprise socio-demographic characteristics of health worker that are important for
analysis, and the second part of the questioner comprised of rating scale items which enable to
collect information on the perception of health worker towards their institutional structure and
leadership, and they were adopted from related research undertaken at four hospitals in Nigeria,
and some of them were adopted and modified from a guide Enhancing Organizational
Performance: a Toolbox for Self-Assessment published by the International Development
Research Centre (14,33).
5.5.2 Personnel recruitment and training
One data collectors for each hospital who had diploma and work in Chiro Primary school having
two years experience were used. The data collectors was recruited and trained for one day on the
objectives of the study, instrument, how to collect data and how to conduct supervision, at Rift
Valley University College, Chiro town.
5.5.3 Data collection procedures
Structured self administered questioner was used to collect data. The questionnaires had two
parts. Part one has some closed-ended questions that help to assess socio-demographic
characteristic and part two questions are answered on a 5-point Likert scale i.e., 1 = strongly
Disagree, 2 = Disagree, 3 = undecided, 4 = agree and 5 = Strongly Agree and helps to assess the
perception of health worker towards institutional structure and leadership.
Data collectors gathered information from health workers willing to participate based on the
inclusion and exclusion criteria stated. During data collection, close supervision was carried out
to overcome any mistakes from data collectors. On each data collection day, the collected data
12
was reviewed; and principal investigator was responsible to coordinate the overall activities of
data collection.
5.5.4 Study Variables
Dependant variables
Health workers perception towards institutional structure
Health workers perception towards organizational leadership
Independent variables
Age
Sex
Marital Status
Level of Education
Profession
Position
Hospital
Income
Service Year
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5.6 Operational definition
Leadership: the ability of administrative body of the two hospitals to influence, motivate, and
enable others to contribute toward the effectiveness and success of the organizations of which
they are members and have the following quality
o Communicates the vision or goal with employees
o Ability to create and maintain a culture of safety and quality throughout the
hospital.
o Makes space and equipment available as needed for the provision of care,
treatment, and services.
o Have a knowledge needed for their role
o helps an organization to be successful and create the future it wants
Health worker Perception: a process by which individuals organize and interpret their sensory
impressions in order to give meaning to their environment and not necessarily based on reality,
but is merely based on perspective of health worker towards
Institutional structure and
Leadership of Chiro and Gelemso hospitals’.
There were 26 items used to assess perception of health worker towards institutional structure
and leadership. Among 26 item, 17 item were used to asses’ institutional structure and the
remaining for institutional leadership. These 26 items were measured on a 5-point likert scale for
responses (Strongly disagree, Disagree, Undecided, Agree and strongly agree). For descriptive
analysis Response strongly agrees and agrees had taken as positive response and responses
undecided, disagree and strongly disagree considered as negative response.
To explore factors that affect perception of health workers, the assigned weights “1” for
strongly disagree to “5” for strongly agree were added together. Then by using the summated
scale multiple linear regressions were used in order to identify the predictors for the outcome
variable.
14
Perception of Institutional structure: is defined as perception of health worker of Chiro or
Gelemso towards
• Organizational climate
• Human resource
• and Infrastructure
Perception of Organizational climate: denotes perception of health workers of Chiro or
Gelemso Hospitals whether the Hospitals are pleasant place to work, Values their employees ,
give enough emphasis on the quality of service it provides and open to their ideas.
Perception of Human resource: denotes perception of health workers of Chiro or Gelemso
Hospitals whether the Hospitals have adequate staff , Compensation is fair, recruitment and
hiring policy is clear and Staff are held accountable for getting work done according to clear
performance standard.
Perception of Infrastructure: perception of health workers of Chiro or Gelemso Hospitals
whether the Hospitals: have needed technological resources for health sector reform, manage its
technological resource effectively, have Adequate facilities and equipment and Facilities and
equipment well maintained.
Health worker: are health professionals who are at work in Gelemso or Chiro Hospitals and
include
Specialist
Medical doctor
Nurses
Health officer
Laboratory Technologist/Technician
Dentists
Pharmacy Technician/pharmacist
Other who are graduated with health science
15
Facility: a place where health worker carry out their tasks. It includes;
o Availability of necessary materials( the hospital have of all the
necessary materials or instrument used to perform procedures)
o Adequacy of materials (no shortage of material that are needed to
provide care for patient, such as, delivery set, glove, antiseptic )
o Cleanness of the working environment( room does not have
offensive odor, well ventilated and regularly cleaned by cleaners)
Training and Development: the hospital staff development program. It includes;
o Academic career development( offer opportunity to upgrade their
status)
o Encourage gap feeling program( provide training for health
worker to become aware on new approaches and program)
o Make informed health worker with new guide line as necessary
o refresh health worker to maintain their knowledge
Staff Promotion: It implies a raise in pay, benefits, and responsibility in relation with staff
performance.
Technological Resources: it implies existence of essential technologies that are expected the
hospital to have, such as, Electricity, refrigerators, X-ray machine, various examinations sets…..
Position: role of health worker in an organization. It could be;
Ward head
Matron
Case team leader or other
5.7 Data analysis
The collected data was critically checked for its completeness, and then coded, edited, entered,
and cleaned using SPSS version 16. Reliability tests were employed on SPSS to check the
instrument internal consistency.
16
Univariate analysis was used to describe each individual variable using mean, median, standard
deviation and other methods. Multiple Linear Regression ware applied to explore effects of
independent variables on an outcome. Adjusted R2 (Coefficient of determination) used to
Measure a total variation in outcome which was explained by all regression variables, Variables
with a p value less than 0.05 had taken in to the fit model. And the General formula with k
exposure variables is:
y = β0 + β1x1 + β2x2 + … + βkxk
β0 = constant
β1, β2,… βk = adjusted regression coefficients
Finally data were interpreted and summarized using simple frequency tables, graphs and charts.
5.8 Data quality management
One-day training for data collectors was given. Questionnaires were checked by principal
investigator for omissions and incomplete answers. Responses were then carefully coded, with
verification.
After checking all questionnaires for consistency and completeness the supervisors had
submitted the filled questionnaire to the principal investigator. And, prior conducting the actual
study, 5% of the questionnaire/tool was pre-tested in Bishoftu hospital for precision, sequence,
simplicity and soundness.
5.9 Ethical Consideration
Ethical clearance was obtained from Ethical Review Board Jimma University College of Public
Health and Medical Sciences. Both hospital were well informed about the study and agreed and
allowed for the study to be conducted. Informed consent was obtained from all study subjects
before conducting the actual study.
Name of the study subjects remain anonymous or any identification had not written on
questioner. The respondent was assured that the information taken from them was kept
confidential and informed as data is only for the study purpose.
17
5.10 Limitation ion of the study
Some study unit were unwilling to participate
Social desirability Bias
5.11 Dissemination plan
The findings of the study will be submitted to Jimma University College of Public Health and
Medical Sciences. Following submission, the results will be publicly defended in the University.
After the approval of the findings by the Department of Health Services Management, copies
will be distributed to Chiro and Gelemso hospital and west Hararghe Zonal health department
and Oromia regional health bureau. Efforts will be made to publish the finding
in reputable journals.
17
Chapter Six: Results
1. Basic characteristic of the respondents
A total of 204 health workers agreed to participate in the study out of 218 giving a response rate
of 93.6%. About 84% of the respondents were between 21 and 30 years. The minimum and
maximum age of the participant was 21 and 54 respectively, the median age of the participants
were 25 with a SD of 6.1(table1). About 80% of the participants were less than six years service
and SD of 3.8 years and the maximum service year was 25 years.
Table1: Age and service year of Chiro and Gelemso hospitals health workers, east
Ethiopia, 2012
Variables Mean Median Std. Deviation Range Minimum Maximum N=204
Age 27.34 25.00 6.157 33 21 54
Service Year 4.4608 3.0000 3.81641 23.00 2.00 25.00
There were more Males 50.5% than Females which accounts 49.5%, Majority of Chiro Hospital
health workers were females which accounts 56.2% while majority of Gelemso hospital health
workers were Males which accounts 56.5% (Table2).
About 50% of the respondents were single. Just about 67% of the respondents were Nurses;
Majority of the respondents (52.9%) was from Gelemso hospital and only 27 health workers had
position in the hospital (Table 2).
18
Table 2: Basic Characteristics of health workers of Chiro and Gelemso hospitals, east
Ethiopia, 2012
Sex Frequency
N=204 Percent
Male 103 50.5%
Female 101 49.5%
Marital Status
Single 102 50.0
Married 95 46.6
Divorced & Widowed 7 3.5
Religion
Muslim 59 28.9
Orthodox 93 45.6
Protestant 34 16.7
Catholic 11 5.4
Others 7 3.4
Ethnicity
Oromo 92 45.1
Amhara 69 33.8
Others 43 21.1
Hospital
Chiro 96 47.1
Gelemso 108 52.9
Profession
Physician 15 7.4
Nurse 136 66.7
Others 53 26.0
Position
Staff 177 13.2
Head 27 86.8
19
2. Institutional structure and leadership
The instrument used to asses perception of health worker towards institutional structure and
leadership had a good internal consistency with a Cronbach’s of alpha =0.927 and 0.906
respectively.
2.1 Perception of Health workers towards Institutional structure and Leadership of
Gelemso and Chiro Hospitals
There were twenty six (26) items on the perception of institutional structure and leadership. The
items with the highest and lowest perception were listed under the infrastructure dimension. The
institution has needed technological resources for health sector reform had the highest perception
(58.3) and Facilities and equipment well maintained had lowest perception (21.1%) (Table: 4).
The percentage ratings of the healthcare workers’ responses to the statements on the four
dimensions of institutional structure and leadership of Chiro and Gelemso Hospitals are indicated
in the tables below.
2.1.1 Perception of Organizational Climate
About 46.1% of the respondents agreed and strongly agreed that their hospitals had “a pleasant
place to work” (mean= 3.03, SD= 1.137). More than 61% of the respondents perceived that as
their hospitals did not Values its employees. 40.7% of the respondents perceived that their
hospitals would give enough emphasis to the quality of service it provides (mean=3.029,
SD=1.17). 69.1 % of the respondents perceived that as their hospital didn’t pay competitive
salary. The vast majority (66.6%) of the respondents perceived that as their hospitals didn’t give
an equal opportunity to employees (mean= 2.70, SD= 1.30) (Table 3).
2.1.2 Perception of Infrastructure
A majority (58.3%) of the respondents perceived that their hospitals had “needed technological
resources for health sector reform” (mean=3.28, SD=1.12). 65.2% of the respondents perceived
that their hospitals did not manage its technological resource effectively (mean=2.96, SD=1.13)
(Table 4).
20
2.1.3 Perception of human resources
About 59.8% of the respondents did not perceived that their hospitals had “adequate staff in all
key positions for health sector reform” (mean=2.86, SD=1.21). Only 36.3% of the respondents
perceived that “staff are qualified and considered competent” (mean=2.90, SD=1.06). 63.7% of
the respondents did not perceived that their hospital had “opportunities exist for staff
development and training” (mean=2.81, SD=1.16) (Table 5).
2.1.4 Perception of Institutional leadership
About 37.8% of the respondents perceived that their hospital had “leaders that the organization
needs to be successful”. 67.2% of respondents did not perceived that “There is a formal problem
solving in the hospital” (mean=2.70, SD=1.17). About 43.7% of the respondents disagreed or
strongly disagreed that the “The hospital’s have clear structure and the decision-making process”
(mean=2.83, SD=1.14) (Table 6).
21
Table 3: Health worker perception of organizational climate of Chiro and Gelemso Hospitals, East Ethiopia, 2012
organizational climate Item
Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
Mean Median Std.
Deviation
N
The Hospital is a pleasant place to work 9.3 29.4 15.2 40.7 5.4 3.0343 3.0000 1.13771 204
The Hospital Values its employees 13.7 31.4 16.7 29.4 8.8 2.8824 3.0000 1.22610 204
The Hospital can give enough emphasis on the
quality of service it provides
9.8 27.9 21.6 30.9 9.8 3.0294 3.0000 1.17407 204
The Hospital pay competitive salary 24.0 27.9 17.2 29.4 1.5 2.5637 2.0000 1.18731 204
The organization is open to my ideas and
suggestions
16.2 31.9 23.0 21.6 7.4 2.7206 3.0000 1.18503 204
The Hospital give an equal opportunity employees 20.1 33.3 13.2 23.0 10.3 2.7010 2.0000 1.30320 204
22
Table 4: Health worker perception of Infrastructure of Chiro and Gelemso Hospitals, East Ethiopia, 2012
Infrastructure Item Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
Mean Median Std.
Deviation
N
The institution has needed technological resources for
health sector reform
7.4 23.0 11.3 50.5 7.8 3.2843 4.0000 1.12629 204
The Hospital manage its technological resource
effectively
9.8 27.5 27.9 26.0 8.8 2.9657 3.0000 1.13337 204
Adequate facilities and equipment are available to support
operations for the health sector reforms
9.3 34.8 25.5 22.5 7.8 2.8480 3.0000 1.11481 204
Facilities and equipment well maintained 11.8 33.3 33.8 18.6 2.5 2.6667 3.0000 .99093 204
23
Table 5: Health worker perception of Human Resource of Chiro and Gelemso Hospitals, East Ethiopia, 2012
Human Resource Item Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
Mean Median Std.
Deviation
N
The Hospital has adequate staff in all key position for
health sector reform
15.2 29.4 15.2 33.8 6.4 2.8676 3.0000 1.21855 204
Staff are adequate and considered competent 6.4 37.7 19.6 31.4 4.9 2.9069 3.0000 1.06727 204
Compensation is adequate and for attracting and
keeping key staffs
9.8 23.0 31.9 28.4 6.9 2.9951 3.0000 1.08957 204
The Hospital support staff training and development 14.2 30.9 18.6 31.4 4.9 2.8186 3.0000 1.16663 204
The Hospital recruitment and hiring policy is fair 15.2 36.8 14.7 24.5 8.8 2.7500 2.0000 1.23226 204
Staff are held accountable for getting work done
according to clear performance standard
6.9 17.6 27.9 40.7 6.9 3.2304 3.0000 1.04144 204
Promotions are based primarily on performance 11.8 24.0 22.5 30.4 11.3 3.0539 3.0000 1.21243 204
24
Table 6: Percentage rating of the perception of health workers towards Leadership of Chiro and Gelemso Hospitals,
2012
Leadership Item Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
Mean Median Std.
Deviation
N
We have the leaders that the organization need to be
successful 15.7 24.0 22.5 30.9 6.9 2.8922 3.0000 1.20268 204
My supervisor treat all employees in my work unit
equitably 13.2 36.8 27.0 20.1 2.9 2.6275 2.5000 1.04029 204
There is a formal problem solving in the hospital 15.7 36.3 15.2 27.9 4.9 2.7010 2.0000 1.17603 204
A shared plan among members to achieve the goal 10.3 28.4 30.4 29.4 1.5 2.8333 3.0000 1.01305 204
The governing body are ultimately accountable for the
safety and quality of care, treatment, and services 12.3 30.4 25.0 28.4 3.9 2.8137 3.0000 1.09841 204
The governing body have the knowledge needed for
their roles in the hospital 16.2 35.8 21.1 24.5 2.5 2.6127 2.0000 1.09726 204
The hospital’s have clear structure and decision-making
process 11.8 31.9 25.0 23.5 7.8 2.8382 3.0000 1.14827 204
Work closely with health workers to create the
hospital’s mission, vision, and goals. 15.2 31.4 21.1 26.5 5.9 2.7647 3.0000 1.17172 204
The hospital provides the resources needed 10.8 27.0 25.0 32.4 4.9 2.9363 3.0000 1.10568 204
25
5.2. Factors that affect perception of Health workers towards institutional
structure and leadership
2.2.1 Factors that affect perception of health workers towards institutional structure
Hence, distribution residual is normal as shown in the Histogram and P-P plot, the relationship between
outcome and explanatory variable is linear and observations are Independent, multiple linear regression
were applied.
Fig.2: A Histogram that show the distribution dependent variable against the predictors
Fig.3: A P-P that show the distribution dependent variable against the predictors
26
Table 7: Variation of the outcome variable explained by predictors, East Ethiopia, 2012
Model R R Square Adjusted R Square
Std. Error of the
Estimate
1 .305a .093 .089 12.73410
2 .343b .117 .109 12.59216
3 .370c .137 .124 12.48248
a. Predictors: (Constant), Educational status of the respondent
b. Predictors: (Constant), Educational status of the respondent, Position of the respondent
c. Predictors: (Constant), Educational status of the respondent, Position of the respondent,
Experience they have in the hospital
d. Dependent Variable: Perception of health worker towards institutional structure
27
Table 8: predictors of perception of health workers towards institutional structure, East Ethiopia, 2012
a. Dependent Variable: Perception of health worker towards institutional structure (PHWI)
b. “0” for Some position in the hospital and “1” for staff
c. “0” for health worker who have bachelorette/Master and “1” for Diploma/Level IV
PHWI = 51.76 - .49(age) + 6.13(position) – 8.83(Edustatus)
From this;
One year increase in age will decrease the perception of 0.49 after making all other independent variables
under control
Being staff will increase the perception of health workers towards institutional structure by 6.13after making
all other independent variables under control
Having Diploma/Level IV holder will lessen the perception health workers towards institutional structure by
8.83 after making all other independent variables under control
Model Unstandardized Coefficients Standardized
Coefficients Sig. 95% Confidence Interval for B
B Std. Error Beta Lower Bound Upper Bound
Constant 51.763 2.751 .000 46.338 57.187
Experience -.490 .230 -.140 .034 -.943 -.037
Position 6.139 2.599 .156 .019 1.015 11.263
Edustatus -8.833 1.827 -.320 .000 -12.436 -5.231
28
2.2.1 Factors that affect perception of health workers towards institutional structure
Hence, distribution residual is normal as shown in the Histogram and P-P plot, the relationship between
outcome and explanatory variable linear and observations were Independent, multiple linear regression
were applied.
Fig. 4: A Histogram that show the distribution outcome variable against the predictor
Fig.5: A P-P that show the distribution dependent variable against the predictor
29
Table 9: predictors of perception of health workers towards institutional leadership, East Ethiopia, 2012
a. Dependent Variable: Perception of health worker towards leadership
b. “0” for health worker who have bachelorette/Master and “1” for Diploma/Level IV
PHWL = 26.77 – 2.05(hospital) + 2.18(Edustatus)
From this;
Serving in Gelemso hospital would lessen the perception of health workers towards institutional
leadership by 2.05 after making all other independent variables under control
Model Unstandardized Coefficients Standardized
Coefficients Sig. 95% Confidence Interval for B
B Std. Error Beta Lower Bound Upper Bound
(Constant) 26.779 1.740 .000 23.347 30.211
Hospital -2.052 1.077 -.135 .008 -4.175 .072
Edustatus 2.180 1.115 .139 .012 .019 0.378
30
Chapter Seven: Discussion
7.1. Perception of health workers towards institutional structure and leadership
This study was identified the perception of health worker towards their institutional structure and
leadership and factor that are associated with it. The overall perception of institutional structure
and leadership in this study were 37.2% and 31.6% respectively. Out the three dimension
perception to human resource have the highest perception which accounts 38.67% while
perception to organizational climate and Infrastructure accounts 36.36% and 36.12%
respectively. This perception of health workers towards their institutional structure was very
much lower than the situation in Nigeria which accounts 52.2 % (12).
Perception of Organizational Climate
The overall Perception of Organizational Climate was 36.36%. About 59% of the respondents
perceived that as their Hospital did not give enough emphasis on the quality of service it provides.
About 69.1% of the respondents perceived that as their hospital were not pay competitive salary for
its employees.
In the study by Agyepong and others in Ghana, in January 2002, 94% out of 551 healthcare
workers and 95% out of 614 in August 2003 mentioned low salary as a workplace obstacle
affecting staff performance (36).
This finding is quite similar with countries like Namibia, Nigeria and Ghana. In Namibia, One of
the most significant complaints pointed out by most categories of health professionals were lack
of competitive salary, which makes them very dissatisfied and enable them to develop
unfavorable perception towards institutional structure (34).
Perception of Infrastructure
A total perception of infrastructure was 36.12% and majority of the health workers (69.6%)
perceived that there were inadequate facilities and equipment in their hospitals and a very high
proportion (78.9%) perceived that the available facilities and equipment were poorly maintained.
A study which was conducted in Nigeria four Hospitals revealed that a majority of the healthcare
workers (69.9%) perceived as there were inadequate facilities and equipment in their hospitals
and a similar proportion (69.4%) perceived that the available facilities and equipment were
31
poorly maintained (12). In a study of 551 health care workers in Ghana in January 2002,
Agyepong et al. reported that 75% mentioned lack of essential equipment, tools and supplies as a
workplace issue affecting staff performance (36).
The rather low perception of health workers may be a reflection of the poor state of the
infrastructure available to deliver health care services in Chiro and Gelemso.
Perception of Human Resource
The overall Perception of Human Resource was about 39%. Amongst the items that make up the
human resources dimension, 59.8 % of the respondents perceived that their hospitals did not
have adequate staff in all key positions. This is similar to the report from a study of 614 health
care workers in Ghana in August 2003. Agyepong et al. reported that 63% mentioned inadequate
staffing as a workplace obstacle affecting staff performance and Nigeria which was also revealed
71.1% of the respondents perceived that their hospitals did not have adequate staff in all key
positions (12, 36). Another 74% of the respondents in this study also perceived as poor
compensation had an issue that hinder the recruitment and retention of staff and a similar finding
was obtained from the study conducted in Nigeria where 73.4% of health care workers
perceived as poor compensation as an issue hindering the recruitment and retention of staff(12).
Perception of Leadership
The overall Perception of In this study was 31.6%, only 32.8% of the respondents perceived that
there is a formal problem solving in the hospital. Only 27 % (mean=2.61, SD=1.09) of the
respondent had perceived that as the governing body have the knowledge needed for their roles
in the hospital. And it was also revealed that as the hospital leadership is very poor, these was
mainly contributed to knowledge of the governing party and lack a shared plan had also a major
problem in this study which account about 69.1%. But, study in Nigeria was revealed only
33.6% of the respondents perceived that the span of control and supervision was not reasonable
(12), which is much better from the finding in this study by which 68.7% health workers did not
perceived that The hospital’s have clear structure and decision-making process .
32
7.2. Factors that affects Perception of health professionals towards institutional structure
and Leadership
Variables Age, Position and Educational status had an independent effect on perception of
health workers towards institutional structure.
And Place of work (Hospital) and Educational status were an independent explanatory variable
for the perception of health workers towards institutional leadership.
33
Chapter Eight: Conclusion and Recommendation
8.1. Conclusion
General speaking, perception of health worker towards their institutional structure is
poor. This is substantiated as, majority of the health workers from two hospitals had
perceived as their hospitals
were not pleasant place to work
would not pay competitive salary
as recruitment and hiring policy was not fair
Promotions were not based primarily on performance
Staff were not held accountable for getting work done according to clear
performance standard
Staff were not adequate and considered competent
Would not Values its employees
Likewise, perception of health worker towards institutional leadership is not good enough
this was authenticated because of the majority of health workers from both hospitals
perceived
o As they would not have leaders that the organization needs to be successful
o There were no formal problem solving in the hospital
o Would not have clear structure and the decision-making process
Educational status, age and position are the factors that are identified in this study which
determine the perception of health workers towards their institutional structure while
work place and Educational status for institutional leadership
34
8.2. Recommendation
For Administrators of the Two Hospitals:
They hospitals should have to promote health workers primarily based on their
performance.
They have to give formally the role and responsibilities of health workers in order to
make staffs accountable for the thing they did it.
They should have to give an equal opportunity to their employees on staff training and
development.
They have to strength and maintain their Facilities and equipment.
They have to work closely with health workers to create the hospital’s mission, vision,
and goals.
For Zonal health Department and Regional health bureau
Should have to create a Compensation mechanism, for example increasing per diem for
duty work.
Have to Work closely with Chiro and Gelemso hospital in order to identify staffs which
are not competent and fill their gap via providing comprehensive staff training.
Have to support on equipping the facility of the two hospitals.
Have to undertake a study to know perception health workers who work at health center
and health posts.
35
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39
ANNEXES: I
Questionnaire
Dear respondent, this study is carried out to assess your perception toward the organization
institutional structure and leadership. Undertaking this study may help to identify the factors that
affect the perception of health worker towards their institutional structure and leadership and
provide a recommendation primed to improve the health service that enhances quality of the
organization.
Over and above, I want to remind you that, all the information that you offer for me is very
substantial and kept confidential. To make this reliable your name is not written in this
questioner.
At last, I benevolently request your voluntary co-operation on answering the questions here
under, it will take only 15 – 20 minutes and you have the right not participate on the study.
If you decided and fascinated, let us begin!! If no!! Thank you!!!
Thank you, for your time!
40
Part One: Background Information
501.What is name of the hospital?
1. Chiro
2. Gelemso
502.What is your position in the hospital? (Title)
1. Head Nurse
2. Medical Director
3. Staff
4. Matron
5. If other, specify______________
503.What is your profession?
1. Physician
2. Nurse
3. Health Officer
4. Laboratory
Technician/Technologist
5. Pharmacist/ Pharmacy Technician
6. If other specify,____________
504.Educational Level
1. Master
2. BSC
3. Diploma
4. Level IV
5. Other specify__________
505.Sex
1. Male
2. Female
506.Marital Status
1. Married
2. Single
3. Divorced
4. Widowed
507.Religion______________
508.Ethnicity_____________
509.How long have you been working in this hospital? _______
510.How old are you? _________ Years old(complete year)
511.How much is your monthly income? _______________
41
Part Two:
Session One
Session Two
I would like to find out how you feel about the organizational climate. Please help me by answering the
following questions. (perception of Health worker towards organizational climate)
Sr.
No.
Strongly
Disagree(1)
Disagree(2) Undecided(3) Agree(4) Strongly
Agree(5)
501 The Hospital is a pleasant place to work
502 The Hospital Values its employees
503 The Hospital can give enough emphasis
on the quality of service it provides
504 The Hospital pay competitive salary
505 The organization is open to my ideas and
suggestions
506 The Hospital give an equal opportunity
employees
I would like to find out your perception on Infrastructure that the health sector have
Sr.
No.
Strongly
Disagree(1)
Disagree(2) Undecided(3) Agree(4) Strongly
Agree(5)
507
The institution has needed
technological resources for health sector
reform
508 The Hospital manage its technological
resource effectively
509 Adequate facilities and equipment are
available to support operations for the
health sector reforms
510 Facilities and equipment well
maintained
42
Session three
I would like to find out your perception of Human resource
Sr.
No.
Strongly
Disagree(1)
Disagree(2) Undecided(3) Agree(4) Strongly
Agree(5)
511 The Hospital has adequate staff in all
key position for health sector reform
512 Staff are adequate and considered
competent
513 Compensation is adequate and for
attracting and keeping key staffs
514 The Hospital support staff training
and development
515 The Hospital recruitment and hiring
policy is fair
516 Staff held accountable are held
accountable for getting work done
according to clear performance standard
517 Promotions are based primarily on
performance
43
I would like to find out your perception towards the Institutional leadership
Sr.
No.
Strongly
Disagree(1)
Disagree(2) Undecided(3) Agree(4) Strongly
Agree(5)
518 We have the leaders that the
organization need to be successful
519 My supervisor treat all employees in
my work unit equitably
520 There is a formal problem solving in
the hospital
521 A shared plan among members to
achieve the goal
522
The governing body are ultimately
accountable for the safety and
quality of care, treatment, and
services
523
The governing body have the
knowledge needed for their roles in
the hospital
524 The hospital’s have clear structure
and the decision-making process
525
The governing bodies work closely
with health workers to create the
hospital’s mission, vision, and goals.
526
The hospital provides the resources
needed for data and information use,
including staff, equipment, and
information systems.
Session four
Top Related