Strathmore University SU+ @ Strathmore University Library Electronic Theses and Dissertations 2018 Effects of working environment on job satisfaction among Physicians in Public Health Sector of Nairobi County Stellah W. Bosire Institute of Healthcare Management Strathmore University Follow this and additional works at https://su-plus.strathmore.edu/handle/11071/6106 Recommended Citation Bosire, S. W. (2018). Effects of working environment on job satisfaction among physicians in Public Health Sector of Nairobi County (Thesis). Strathmore University. Retrieved from https://su-plus.strathmore.edu/handle/11071/6106 This Thesis - Open Access is brought to you for free and open access by DSpace @Strathmore University. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of DSpace @Strathmore University. For more information, please contact librarian@strathmore.edu Effects of Working Environment on Job Satisfaction among Physicians in Public Health Sector of Nairobi County. STELLAH WAIRIMU BOSIRE 88946 Submitted in Partial Fulfilment of the Requirements for the Degree of MBA- HCM at Strathmore University Faculty of Business Strathmore University Nairobi, Kenya Institute of Healthcare Management Strathmore University Nairobi, Kenya 2018 ii Declaration I declare that this work has not been previously submitted and approved for the award of a degree by this or any other University. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself. Stellah Wairimu Bosire [Name of Candidate] ............................................... [Signature] ............................................... [Date] Approval The thesis of Stella Wairimu Bosire was reviewed and approved by the following: Supervisor Dr. Fredrick Ogola Senior Lecturer, MBA ............................................... [Signature] ............................................... [Date] Head of School/Institute/Faculty School Name Dean, School of Graduate Studies ............................................... [Signature] ............................................... [Date] iii Abstract Job satisfaction is the feeling of pleasure and achievement that one experiences in his/her job when they know that their work is worth doing; or the degree to which work gives feeling of pleasure.WHO refers to human resource for health as the engine that propels health systems. The presence of a highly skilled and motivated workforce is key to optimal health service delivery. While employees exist to achieve the goals of the organization, a dissatisfied employee is likely to leave the organization. The purpose of the study is to assess the effect of working environment on job satisfaction among physicians of Nairobi. The research questions that guided this study include; finding out the relationship between job satisfaction and training among physicians in public sector of Nairobi, the relationship between engagement and job satisfaction among physicians in public sector of Nairobi, the relationship between job security and job satisfaction among physicians in public sector of Nairobi and the relationship between physical working environment and job satisfaction among physicians in public sector of Nairobi. A descriptive research design was adopted, with physicians in Nairobi being the focus. The population of interest was the physicians in Nairobi. Data was analyzed using statistical methods that is, descriptive statistics describing the correlation using Pearson correlation. By researching the relationship between the working environment and job satisfaction, it becomes evident that the county of Nairobi it becomes evident that despite the multiple unrest in the health sector, very little has been done to understand what ails the human resource for health in Nairobi county. This research findings indicate that training, engagement, job security and the physical working environment have a positive correlation with job satisfaction. Further, the research reflects that although some efforts have been made to improve the working environment, there is dissatisfaction among the physicians in public sector of Nairobi who particularly ranked training as the most crucial factor that influenced job satisfaction. iv TABLE OF CONTENTS Declaration................................................................................................................................................... ii Approval ...................................................................................................................................................... ii Abstract ....................................................................................................................................................... iii List of Figures ............................................................................................................................................. vi Definition of Terms ................................................................................................................................... vii Dedication ................................................................................................................................................... ix CHAPTER ONE: INTRODUCTION TO THE STUDY ........................................................................ 1 1.1 Background Information ................................................................................................................ 1 1.2 Statement of the Research Problem .............................................................................................. 2 1.3 Objective of the Research ............................................................................................................... 3 1.4 Specific Objectives .......................................................................................................................... 3 1.5 Research Question .......................................................................................................................... 4 1.6 Significance of the Study ................................................................................................................ 4 1.7 Scope of the study ............................................................................................................................ 5 1.8 Study Outline ................................................................................................................................... 5 CHAPTER TWO: LITERATURE REVIEW .......................................................................................... 7 2.1 Introduction ..................................................................................................................................... 7 2.2 Theoretical Review. ......................................................................................................................... 7 2.3 Empirical Review ............................................................................................................................ 9 2.4 Research Gap ................................................................................................................................ 12 2.5 Conceptual Framework ................................................................................................................ 12 2.6 Conclusion ..................................................................................................................................... 13 CHAPTER THREE: RESEARCH METHODOLOGY........................................................................ 14 3.1 Introduction ................................................................................................................................... 14 3.2 Research Design ............................................................................................................................ 14 3.3 Population and Sampling ............................................................................................................. 14 3.4 Data Collection Methods .............................................................................................................. 15 3.5 Pilot study ...................................................................................................................................... 16 3.5.1 Reliability of data collection instrument ................................................................................. 16 3.5.2 Validity of data collection ......................................................................................................... 17 3.6 Data Analysis Methods ................................................................................................................. 17 3.7 Ethical Consideration ................................................................................................................... 17 v 3.8 Conclusion ..................................................................................................................................... 18 CHAPTER FOUR: PRESENTATION OF RESEARCH FINDINGS ................................................. 19 4.1 Introduction ............................................................................................................................ 19 4.2 Response Rate .......................................................................................................................... 19 4.3 Demographical Data ................................................................................................................. 20 4.3.1 Response rate by Gender and Age ........................................................................................... 20 4.3.2 Respondents Facility and Designation .................................................................................... 21 4.4 Specific Analysis ........................................................................................................................ 22 4.4.1 Influence of training on job satisfaction among physicians .................................................. 22 4.4.2 Influence of job engagement on job satisfaction among physicians ..................................... 25 4.4.3 Establish the influence of job security on job satisfaction among physicians ..................... 28 4.4.4 Establish influence of working environment on job satisfaction among physicians. .......... 31 4.5 Effects of working environment to job satisfaction among physicians in public sector ..... 33 4.6 Conclusions .......................................................................................................................................... 35 CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS............................. 36 5.1 Influence of training on job satisfaction among physicians ...................................................... 36 5.2 Influence of engagement on job satisfaction among physicians ................................................ 37 5.3 Influence of Job security on job satisfaction among physicians ............................................... 38 5.4 Influence of physical working environment on job satisfaction among physicians ................ 40 5.5 Recommendation ........................................................................................................................... 40 5.5.1 Practical Implications for decision makers ................................................................................ 40 5.6 Suggestions for further research ................................................................................................. 42 6.0 References ...................................................................................................................................... 43 Appendix I: Cover Letter ......................................................................................................................... 52 APPENDIX I1: QUESTIONNAIRE ....................................................................................................... 53 vi List of Figures Figure 1: Abraham Maslow’s hierarchy of needs. There are five levels of needs. The hierarchy of needs is a step wise pyramid where the lower needs have to be met before the higher needs. ............................... 8 Figure 2: Researcher own, 2018 – Conceptual framework, effects of working environment on job satisfaction. ................................................................................................................................................. 13 Figure 3: Distribution of Respondents by Gender and Age ........................................................................ 20 Figure 4: Distribution of Respondents by Facility and designation ............................................................ 21 Figure 5: Mean scores of the determinants of training factor ..................................................................... 23 Figure 6: Mean scores of the determinants of engagement factor .............................................................. 26 Figure 7: Mean scores of the determinants of Job Security ........................................................................ 29 Figure 8: Mean scores of the determinants of physical environment ......................................................... 31 Figure 9: Mean scores of the factors affecting Job satisfaction among physician ...................................... 34 vii Definition of Terms Dual Practise: Refer to holding both a Government and Private Position. This is a physician who attends to patient both in private and public sector and draws remuneration from both sectors. Employees: A person in the service of another under contract of hire, express or implied, oral or written where the employer has the right or power to control and direct the employee in the material detail on how the work is to be performed. Employee Engagement: Employee engagement is the act of an employee being involved in, enthusiastic about, and satisfied with his or her organization. Employee Retention: Employee retention (versus employee turnover) refers to the continued employment of employees. Optimally, high-quality, productive employees are retained. Employee Turnover: Employee turnover (versus employee retention) refers to the process of an employee leaving a position and a new employee hired to take his or her place. Human Resource policies: Rules and guidelines put in place by companies to hire, train, promote, compensate, appraise and terminate employees. Job Satisfaction: The psychological responses to an individual’s job that includes cognitive, behavioural and affective response. Job Security: Assurance (or lack of it) that an employee has about the continuity of gainful employment for his or her work life Physician: A skilled health-care professional trained and licensed to practice medicine licensed by the Kenya Medical and practitioners Board and the Pharmaceutical Board of Kenya and include general practitioner, surgeon, pediatrician, obstetrician and gynecologist, psychiatrist, physicians or any such specialty as may be defined by the two regulatory bodies. Reward: Anything given by organizations to employees in response to their contribution and performance. It may be financial or non-financial reward. Training: Organizational activity aimed at imparting information or instruction to improve the recipient’s performance or to help him or her attain a required level of knowledge and skills. Work environment: Includes the physical environment that includes the overall safety of an employee and the psychosocial working environment of the employee to include among other things job related factors and the social environment that includes interaction of people and their organization. viii Abbreviation CBA- Collective Bargaining Agreement DN- Daily Nation DW- Deutsche Welle DP- Dual Practice HRM – Human Resource Management HRH- Human Resource for Health KMPDB- Kenya Medical practitioners and Dentist Board PLWHA- people living with HIV/AIDS SN- Star Newspaper STATA – Statistics and Data UHC- Universal Health Coverage WB- World Bank WHO – World Health Organization ix Dedication I dedicate this work to God, my family and friends. To my Son Tory James Otieno, for the days I was away, the homework’s I missed, the concerts I came late for, Mum is grateful for your patience. God bless you for your support. 1 CHAPTER ONE: INTRODUCTION TO THE STUDY 1.1 Background Information Globally it estimated that there is a shortage of 17.4 Million health workers out of which, 2.6 million are doctors, 9 million are nurses and the greatest shortage is experiences in Africa and Asia (WHO, 2013) . A world Bank report in 2015 showed that there were 0.2 physicians per 1000 population in Kenya (WB, 2015) against a WHO recommendation of 2.8 physicians/1000 people (WHO, 2015) WHO refers to human resource for health as the engine that propels health systems. The presence of a highly skilled and motivated workforce is key to optimal health service delivery. While employees exist to achieve the goals of the organization, a dissatisfied employee is likely to leave the organization. Job satisfaction is the feeling of pleasure and achievement that one experiences in his/her job when they know that their work is worth doing; or the degree to which work gives feeling of pleasure. Locke defines job satisfaction as pleasurable or positive emotional state resulting from appraisal of one’s job or experiences (Locke, 1969). Job satisfaction has many facets: the affective facet which refers to the emotional feeling of an individual about their job, the cognitive affect that looks at the logical facets of a job such as pay, maternity and the finally individual experience which deals with relationships and wellbeing focusing on working conditions, general well-being and control (Douglas et al., 2008). Job satisfaction is believed to influence turnover, absenteeism, retention and job performance (Judge, Thoresen, Bono and Patton, 2001), (Dieleman, Cuong, Anh, and Martineau, 2003), (Peters et al., 2010). Werner describes five facets of job satisfaction (Bhatnagar and Srivastava, 2012). • The work itself – responsibility, interest, and growth • Quality of supervision – technical help and social support • Relationships with co-workers – social harmony and respect • Promotion opportunities – chances for further advancement • Pay – adequacy of pay and perceived equity vis-à-vis others 2 Ruchi and Surinder (2014) report that the working environment influences the productivity of an individual. The psychological elements of work such as: at levels of satisfaction towards training opportunities, security and motivational factors; rewarding schemes, participation in decision making, and feedback impact the attitudes and behaviours of an individual towards work (Yurtseven and Halici, 2011). The major concern in this study therefore is to find out how by improving the working environment will result in an increase employee job satisfaction, which will translate into, improved job retention and ultimately improve quality of health among Kenyans. Factor analysis was used to identify main factors involved in the workplace and key determinants were assessed with attention to actual and desired workplace characteristics. 1.2 Statement of the Research Problem The constitution of Kenya in Article 43 provides that all Kenyans have a right to the highest standard of health including reproductive health, a provision which confers responsibility to access to health to the Kenyan government (KLRC, 2010). The constitution also provides that the responsibility of health to be shared between the National government and the county government (KLRC, 2010). To guarantee the provision of health to Kenyans, first adequate facilities are to be provide; second, the facilities must be functional with adequate, competent and well motivates staff; third, essential medical commodities should be available and finally adequate financing (Kimathi, 2017). However, the highlights of devolution of health since 2010 include have been negative with; multiple National and county industrial strikes the longest strike of physicians lasting 100 days; poor health care governance with political interference at service delivery and procurement; poor inter-governmental coordination with characteristic public blame game between the National government and the County government; poor management of human resource of health with reports of ethnic profiling, un-procedural discharge from duty, delays in remuneration and National outcry of dissatisfaction among physicians in Kenya (Kibui, Mugo and Nyaga, 2015), (Mwangi, 2013) 3 Despite the number of medical school increasing from two to ten and churning over 600 physicians annually, records report that 30-40 % of the new graduates exit public sector (Magokha, 2015). The latest Ministry of Health worker force survey in 2015 reports that there were 9,499 physicians in Kenya, out of which 5,660 in public practice with a patient ratio of 1: 6,822 (KMPDB, 2017). Due to the dissatisfaction that exist in public sector, many physicians have opted to either take up dual practice or take up private practice. Research has shown that GP prefer Private practice to public practice based on factors such as income, characteristics of the physical working environment, nature of work, leisure, training and intellectual satisfaction (Halvorsen, Steinert, & Aaraas, 2012). A study done among final year students in medical school showed that the students were considering private practice once they graduated driven by speed of paying their debt and gender (Nashleanas, McKernan, Kuthy, & Qian, 2014). With the looming shortage of Physicians in Kenya and Kenya having been categorized by WHO as among the countries with critically low numbers of physician density (WHO, 2015) Objectively, this raises a question whether deliberate efforts have not been made to make the workplace as attractive to the health workforce by for instance ensuring reasonable salaries, better working hours, safe conditions, secure and sufficient management skills (Naburi et al., 2017). 1.3 Objective of the Research The objective of the study was to establish effects of working environment to job satisfaction among physicians in public sector of Nairobi. 1.4 Specific Objectives Specifically, the research sought: i. To establish the influence of training on job satisfaction among physicians in public sector of Nairobi. 4 ii. To establish the influence of job engagement on job satisfaction among physicians in public sector in Nairobi. iii. To establish the influence of job security on job satisfaction among physicians in Public sector of Nairobi. iv. To establish influence of physical working environment on job satisfaction among physicians. 1.5 Research Question This research sought to address the following question; i. What is the relationship between job training and job satisfaction among physicians in public sector in Nairobi? ii. What is the relationship between engagement and job satisfaction among physicians in public sector of Nairobi? iii. What is the relationship between job security and job satisfaction among physicians in public sector of Nairobi? iv. What is the relationship between the physical working environment and job satisfaction among physicians in public sector of Nairobi? 1.6 Significance of the Study Patient outcome have traditionally been attributed to the Triple Aim; reinforcing patient experience, advancing population health and decreasing costs. This however has been disputed with addition of the physician to make the quadruple aim. The quadruple aim expands factors that influence patient outcomes to include refining health and work life balance of health care providers (Bodenheimer and Sinsky, 2014). A satisfied physician will have high productivity and deliver best care to his/her patient. Dissatisfied physicians are more likely to be inefficient and prone to multiple invasive and non- invasive errors risking patient’s life (Williams et al., 2007), (Flotta et al,, 2012). 5 Hospital managers need to create satisfactory environments to decrease turnover and improve retention (Al-Hamdan, Manojlovich and Tanima, 2017). Addressing the number of staff, improve resource allocation to health ultimately improve health outcomes due to improved quality of services rendered (Poghosyan, Liu, Shang and D’Aunno, 2017). This study will provide an in-depth comprehension of these factors and help shape future policy around HRH. There are multiple influencers of the desire of an employee to leave their workplace; poor remuneration, career stagnation or development, lack of opportunities for specialized training, insufficient working and poor living conditions which can be addressed by developing competitive packages (Ojakaa, Olango and Jarvis, 2014). Addressing hygiene factors such as training opportunities, job security according to Herzberg will lead to attracting employees while managing performance by addressing the motivation factors to retain new employees are strategies that can be employed (Purohit and Bandyopadhyay, 2014). There has been minimal study around working environment and job satisfaction among physicians in public sector of Kenya and this therefore remains unexplored and poorly understood 1.7 Scope of the study This study was based in Nairobi and it assessed the physicians in Public Practice County of Nairobi. The study emphasized on Nairobi physician level of satisfaction as relates to the working environment. 1.8 Study Outline This study is divided into five chapters. The chapter one, gives introduction, the background to the study by introducing key concept being studied, problem definition, research objectives, and scope of study and significance of study. Chapter two, presents the literature review organized in three parts: the theoretical framework, the empirical review, research gaps, conceptual framework and conclusion. Chapter three presents the research methodology. It presents the methodology used to collect valid and reliable findings that could address the research questions, 6 the research design, population and sampling, data collection methods, data analysis, research quality and ethical issues in research. 7 CHAPTER TWO: LITERATURE REVIEW 2.1 Introduction This chapter is the base for development of this study. It discusses the applicable literature regarding elements that affect job satisfaction as relates to the working environment. The chapter looks at the theoretical frameworks on job satisfaction, then looks at past studies and reviews some of the existing literature in research. The chapter also provides the conceptual framework between the variables in the study. 2.2 Theoretical Review. These are comprehensive theories that researchers have looked at cutting across factors that are intrinsic to the individual and that are extrinsic and ultimately influence job satisfaction. 2.2.1 Intrinsic and Extrinsic Factors Intrinsic and extrinsic factors stimulate desire in employees to continually be interested in a job. This is due to an interplay among desire, reward and expectations of an employee. The hygiene theory postulates that job satisfaction and dissatisfaction are separate concepts and since they’re viewed as independent; employees are either satisfied or dissatisfied. Offering reasonable wages, job security and a positive workplace culture, interpersonal relationship and working conditions are hygiene factors rather than motivators and whose absence can lead to dissatisfaction and their presence does not motivate or create satisfaction. According to the two-factor theory, there are four possible outcomes. 1. High hygiene + High motivation = Ideal situation, few if any complaints 2. High hygiene + Low motivation = Few complaints but low motivation 3. Low hygiene + High motivation = Motivated employees but dissatisfied 4. Low hygiene + low motivation = dissatisfied and unmotivated employees. This framework identifies job security, appreciation and the work itself as factors of interest for the researcher who will seek to describe the relationship these factors have with job satisfaction among physicians in public health sector in Nairobi county. 8 2.2.2 Hierarchy of needs theory Figure 1: Abraham Maslow’s hierarchy of needs. There are five levels of needs. The hierarchy of needs is a step wise pyramid where the lower needs have to be met before the higher needs. Maslow’s hierarchy of needs was developed to explain human motivation (Maslow, 1943). Abraham Maslow postulates that employees have five levels of hierarchy of needs the lowest on the pyramid are the psychological needs such as remuneration, the next level is safety where employees expect to work in a safe environment, this is followed by the need to belong which in a working environment is influenced by the social relationships that exist Of interest to the researcher is the proposed objective that engagement factors-respect, appreciation-, safety and job security influence job satisfaction and to be able to describe this relationship among physicians in public health sector of Nairobi. 2.2.3 Job Characteristics Model This theory of job design also referred to as job enrichment model looks at job characteristics that have affect work related outcomes. Oldham and Hackman (Richard Hackman and Greg R, Oldham, 1975), propose a five-model job characteristic: skill variety, task identity, task significance, autonomy and feedback which affect motivation, satisfaction, performance, absenteeism and turnover (Oldham and Hackman, 2005). The researcher will seek to describe the relationship of autonomy, task significance and task identity to job satisfaction among physicians in public health sector of Nairobi. 9 2.3 Empirical Review This section presents an empirical literature on the findings of the different studies done on the objectives. In this section, previous studies and their outcomes are presented according to the objectives the researcher was studying, hence the subheadings will include the following. 2.3.1 Effects of training and Development on job satisfaction Continuous professional development aims at improving patient outcome, improving service delivery and advance competency of the individual. Quality of care to patient is significantly affected by training. Organizations that do not develop rewarding schemes for employees by recognizing their effort towards investing in professional development and absence of the recognition can lead to demotivation (Gemeda and Tynjälä, 2015). Training is believed to increase confidence and self-esteem among professional (Kumar et al., 2013). While developing training programs, among factors to consider are age of professional, scope and whether the training aims at broadening knowledge or providing new skills. Training is a career growth booster offering employees an opportunity to advance in their careers, expand knowledge base and adequately develop (Cherian and Jacob, 2013). Employers investing in training employees have been shown to have motivates staffs (Dhar, 2015). By getting these training programs employees are confident, experience transformation of their career, and have positive thoughts for their organization (Ling, Qing and Shen, 2014). Training facilitate employees and employers to align their goals and ultimately achieve their goals (Ford, 2014). Reproductive service delivery competency was reliant on continuous medical training as reported by health care as it enhanced skill variety (Jonas, Crutzen and Reddy, 2017). There is therefore need to develop programs for professional development of employees and this has an effect to the quality of services rendered to the patients (Lima, Jorge, and Moreira, 2006). 10 2.3.2 Effects of Employee engagement on Job satisfaction Engagement refers to an individual’s rational, emotional and behavioral state directed to an organization outcome which significantly affect confinement, productiveness and which can predict the success of an institution and employee job sequel (Shuck and Wollard, 2010). Engagement factors deal with connections, career growth, clarity in dissemination of information, delivery of possibilities, felicitation, contribution, dominance over one’s job, association between employees, reliability in leadership and assurance in the company (Mani, 2011). Striving to remove obstacles and implement behavioral strategies will enhance employee engagement (Seijts, Gerard H and Crim, 2006). Degree of autonomy, sense of accomplishment, professional development, work enrichment and job involvement are factors that have been reported to have a positive correlation with job satisfaction (JYOTI NAIDU, 2016). In a systemic analysis of components influencing recruitment and retention of healthcare workers, the researcher concluded that personal autonomy, maintenance of clinical skills and peer recognition influenced retention of healthcare workers (Mbemba, Gagnon and Hamelin , 2016). Employees engaged in decision making in their organization have been shown to have a higher level of commitment and productivity (Setar, Buitendach and Kanengoni, 2015). Engaged employees have been reported to go an extra mile in ensuring that the allocated responsibilities have been achieved (Govender and Parumasur, 2010). Achievements, appreciation, the work itself, duty and development and are linked with long term positive effects on job performance (Benslimane and Khalifa, 2016). Research has shown that engaged employees affirm their institution, wish to prolong their stay in their employment and exert additional efforts in their organization (Saks, 2006), (JYOTI NAIDU, 2016). 11 2.3.3 Effects of Security on job satisfaction Job security describes how perceive their future in the organization feelings that are subjective and differ among individuals influenced by factors such as their own experiences, the organizational experience and the economic stability of an organization (Mauno et al., 2014). Security of tenure influences job turnover; secure jobs will have a low turnover hence avert costs of with losing of a staff, cost of hiring fresh staff and loss of output that would have otherwise gained if the employee had remained in the organization. Leaders who took an initiative to make employees feel secure, needed and appreciated enhanced employee motivation and commitment particularly in resource constrained environments (Weldegebriel et al., 2016), (Evans et al., 2017). Job security guarantees employee’s retirement security which creates confidence towards the organization ultimately guaranteeing retention (Artz and Kaya, 2014). Employees who no longer believe they can depend on businesses for job security have been shown to have higher stress levels (Artz and Kaya, 2014). Poor remuneration has been cited as a barrier of healthcare workers to render quality services further a factor attributed as a push factor from public service (Alhassan et al., 2013). Purohit and Bandyopadhyay (2014). 2.3.4 Effects of Physical working environment and Job satisfaction The characteristic and the comfort of the external physical working environment is important among physicians. These components include the smells, brightness, moisture-the natural components, availability of the right working tools for the employees to be able to practice their trade, the safety measures of the work place and the hours spent at work (Purpora and Blegen, 2015). On average, a physician will spend at least eight hours in the workplace and within hospital settings, these hours can be more based on clinical occurrences with emergencies requiring spending longer hours at the workplace therefore requiring that the environment be properly maintained so as to help employees accomplish their task (Djukic et al., 2014). 12 Addressing the immediate living environment can lead to appeal and retaining of employees as a means of decreasing employee turnover (Goel et al., 2016). Addressing push factors such as housing, training opportunities, availing opportunities for career development were recommended to address brain drain (Liu et al., 2016). 2.4 Research Gap Based on the literature review, it’s evident that no study has been done on physician job satisfaction in public health sector in Kenya. The issue of work environment and job satisfaction has received minimal research attention in Kenya. This study will seek to fill the existing research gap by conducting by a study on assessing the effect of working environment on job satisfaction among physicians of Nairobi. The research will seek to find out the effect of work environment on employee satisfaction. To the best of the researcher’s knowledge no study has ever assessed the effect of working environment on job satisfaction among physicians of Nairobi. This study comes in handy with an aim of investigating the effects of work environment. 2.5 Conceptual Framework A Conceptual Framework theoretical structure of assumptions, principles, and rules that holds together the ideas comprising a broad concept Working Environment Training Engagement Job security Physical working environment Job satisfaction Employee retention Sense of ownership Level of commitment Productivity Efficiency and effectiveness 13 Figure 2: Researcher own, 2018 – Conceptual framework, effects of working environment on job satisfaction. 2.6 Conclusion This chapter has presented the literature on the study objective. The review comprised the theoretical review, empirical review, gaps the research, and the conceptual framework. The review has been done according to the research objectives. 14 CHAPTER THREE: RESEARCH METHODOLOGY 3.1 Introduction This chapter lays the methodology and It is organized as the research design, target population, sampling techniques and sample size determination, construction of research instruments, pilot study, validity, and reliability of the instruments, methods of data collection, data analysis, and presentation and the ethical consideration. 3.2 Research Design This study used a descriptive survey research design. Descriptive studies describe features associated with the subject population (Taylor, 2005). Descriptive design aids in measuring and finding out the relationships among variables. Quantitative approach was adopted for collecting data as well as analyzing the data. 3.3 Population and Sampling The sample population targeted in this study were physicians in the public sector employed by the county government of Nairobi. A target population is a small portion of the population selected for observation and analysis. Target population also refers to all the members of a population to which research findings can be generalized and is an accurate record of the sampling framework from which the sample is to be drawn (Cochran, 2007). The sample size chosen for the survey was 100 respondents. There are an approximated total number of 363 physicians in Nairobi (WHO SARAM, 2013). The description of the target population was based on all ages, all gender. Primary data was collected from the 100 respondents. The 100 physicians were chosen from 10 vertical subspecialties namely paediatricians, obstetrician and gynaecology, Surgeons (general surgery, Ear nose and throat specialist orthopaedic surgery, urologist, paediatric surgeons, cardiothoracic surgeons, neurosurgeons) internal physicians (nephrologists, endocrinologist, and cardiologists), dentists, psychiatrists, general practitioners, pathologists, anaesthesiologists and radiologists. The rationale for choosing organises specialization was to have a representation of 15 each sub-speciality and because each of the sub-speciality have unique challenges. Random sampling technique will be employed (convenience random sampling) to identify the respondents that will participate on the study (Cochran, 2007). For purposes of maintaining confidentiality, the names of the respondents were kept confidential by coding. Each of the individuals in the study signed a consent form at the beginning of the interview which stated clearly that the study would not contain any information that could be used to identify them. 3.4 Data Collection Methods The current study used both primary and secondary data. Primary data refers to data that is original and collected for the first time (Helen, 2013). Primary data was collected by way of a questionnaire from physicians in public sector of Nairobi County. A questionnaire is a method of collecting data which utilizes a set of questions for collecting data (Saris and Gallhofer, 2014). The reason for use of primary data was to enable the researcher gather information which could not be easily obtained. The primary data collected in the study was be cross-sectional since it collected data at one point of time only. Survey questionnaires comprised of closed ended questions. The questionnaires were designed in accordance with 5-likert scale (Dukes, 2014). The structured questionnaire contains closed ended questions with research objectives and research questions were distributed to respondents to obtain all the relevant information for the researcher to make conclusive remarks. Data was collected from secondary sources such as journals, books, websites, publications and newspapers and other documents available in the library including reports from distinguished academicians (Vartanian, 2011). 16 3.5 Pilot study A pilot study is a mini-version of a full-scale study or a trial run done in preparation of the complete study. A pilot study is also known as a ‘feasibility’ study (Maxwell, 2005). It can also be a specific pre-testing of research instruments, including questionnaires or interview schedules. The pilot study thus followed the researcher had a clear vision of the research topic and questions, the techniques and methods, which were applied, and what the research schedule looked like. The pilot study entail trying out all research techniques and methods, which the researcher had in mind to see how well they worked in practice (Rubin and Babbie, 2009). In this case, the researcher used a pilot study as a pre-testing of the research instrument. The aim of this pilot study was to assess whether the main research project could fail, where research protocols may not be followed, or whether proposed methods or instruments would be inappropriate or too complicated to strike a reasonable balance. A pilot study was be carried out with 10% of the respondents. This was to test for reliability and validity of the data collection instrument. The Cronbach’s Alpha was used to test the validity. That will be if the items on the scale measured the same thing. A value greater than 0.7 was deemed acceptable (Zeller and Carmines, 1980). The results from the pilot study was used to improve and strengthen the data collection instrument especially where the values will be below 0.7 (Gliem and Gliem, 2003.) 3.5.1 Reliability of data collection instrument Reliability is the degree to which an assessment tool produces stable and consistent results. This refers to the extent to which results are consistent over time. The research instrument is considered to be reliable and accurate when the results of a study can be reproduced under a similar methodology (Kirk and Miller, 1986). This study employed Inter-rater reliability which is used to assess the degree to which different judges or raters agree in their assessment decisions. This is useful because human observers will not necessarily interpret answers the same way. This study tested for inter-rater reliability and 17 average inter-item correlation reliability using a pilot test. The pilot study established that questionnaire was reliable and suitable for data collection. 3.5.2 Validity of data collection Validity refers to how well a test measures what it is purported to measure. Validity defines the strength of the conclusive results and whether they can be regarded as accurately describing the real world. An account is valid or true if it represents accurately those features of the phenomena that it is intended to describe, explain or theorize. This study measured the construct validity to ensure that the instrument was measuring the construct it was intended to measure and not the other variables. Construct Validity is used to ensure that the instrument is actually measuring the construct it is intended to measure and not the other variables (Kirk and Miller, 1986). Using a panel of experts familiar with the construct was a way in which this type of validity was assessed. 3.6 Data Analysis Methods The researcher used both descriptive and inferential statistics. In descriptive statistics the researcher focused on the general factors of the study population such as demographics. Also, the researcher analyzed the data using descriptive Statistics to show trends that are summarized generated through STATA output. Since descriptive study could not answer some of the research questions, inferential statistics was also being deployed. The inferential statistics used is Pearson’s correlation. 3.7 Ethical Consideration To maintain a high standard of ethical consideration, the researcher maintained a high level of confidentiality. Personalized information like name, identification number and marital status that were not relevant to the study and that would have identified individual respondents were not included in the questionnaires. The researcher obtained permission from the Strathmore University Institutional Ethical Review Committee. 18 This assured the respondents that the research was purely for academic purpose. Responses from the targeted individuals was not be shared with others and among their peers either. The researcher maintained a high ethical standard by making sure that data used in the study was to be purely obtained from the targeted respondents. 3.8 Conclusion This Chapter describes the methodology and procedures that was to carry out the study. It starts with a brief introduction highlighting the general methodology and structure of the chapter. The chapter also highlights the method that was used to conduct the research and its use justified. The population was defined, and the sampling technique, technique, and sample size described. Finally, the data collection techniques and research procedures to be used have been discussed. The next chapter to follow will be Chapter four which will discuss the Results and Findings of the study. 19 CHAPTER FOUR: PRESENTATION OF RESEARCH FINDINGS 4.1 Introduction The purpose of this study was to establish effects of working environment to job satisfaction among physicians in public sector of Nairobi. To achieve this, the research broke down the study into four key objectives: (1) to establish the influence of training on job satisfaction among physicians in public sector of Nairobi; (2) to establish the influence of job engagement on job satisfaction among physicians in public sector in Nairobi; (3) to establish the influence of job security on job satisfaction among physicians in Public sector of Nairobi and, (4) to establish influence of physical working environment on job satisfaction among physicians. This chapter focuses on the analysis of data collected, its presentation and interpretation by the researcher and is organised around the four objectives. The raw data was analysed using Excel Spreadsheets and STATA statistical software. The results of this analysis have been summarised and presented in the form of charts and tables. Interpretation of the data makes use of both descriptive and inferential statistics. 4.2 Response Rate The study targeted physicians in the public sector employed by the county government of Nairobi. The sample size chosen for the survey was 100 respondents. Primary data was collected from the 100 respondents. The 100 physicians were chosen from 10 vertical subspecialties namely paediatricians, obstetrician and gynaecology, Surgeons (general surgery, Ear nose and throat specialist orthopaedic surgery, urologist, paediatric surgeons, cardiothoracic surgeons, neurosurgeons) internal physicians (nephrologists, endocrinologist, and cardiologists), dentists, psychiatrists, general practitioners, pathologists, anaesthesiologists and radiologists. Table 2 below summarises the response rate. Of the 100 targeted, feedback was received from eighty-six (86), resulting in a response rate of 86%. Data from eleven (14) respondents was not received, forming 14% of the target group. 20 Table 1: Response Rate Category Frequency Percentage Responded 86 86.00 Not responded 14 14.00 Total 86 100.0 Source: Student’s Computation 4.3 Demographical Data This section concerns itself with outlining and presenting the findings obtained from the questionnaires distributed to the respondents. The analysis relied on the information from the respondents so as to classify the different results according to their knowledge and responses. 4.3.1 Response rate by Gender and Age One of the parameters that were to be determined was the gender of the respondents. Since the gender of the respondents. There was a need to ensure that the gender composition is as near as possible to equal numbers. The gender of the respondents was sought since its findings would assist the study categorize respondents based on gender. Figure 3: Distribution of Respondents by Gender and Age Source: Student’s Computation Majority of the responses were obtained from the female respondents. According to the results shown in figure 3(a), 58.1% of the respondents comprised of female physicians while 41.9% of them were male physician. The findings imply that the views expressed in these findings are gender sensitive and can be taken as representative of the opinions of both genders. Female physicians were more satisfied with their work overall with the training, engagement, job security and the physical working environment. 21 The study also sought to investigate the composition of the respondents in terms of age (in years). This aimed at understanding how the respondents were distributed across the various ages and consequently their opinions on the topic of study. From the study, majority of the respondents were aged between 31 years and 40 years, followed by the category of respondents aged between 20 to 30 years, then 51 to 60 years and then 41 to 50 years. No of the respondent was above 60 of age. Respondents aged between the ages of 31 to 60 predominated Nairobi county. These group of physicians ranked training, engagement, job security and physical working environment as important factors of the working environment that influence job satisfaction (Awan and Salam, 2014). While this study did not disaggregate the responses into age, it is important to note that different ages have different training needs literature have shown that younger employees will be more willing to attend training as compared to the older employees (Lee, McNamara, Pitt-Catsouphes, and Lee, 2014) 4.3.2 Respondents Facility and Designation The response rate demonstrates a willingness of the respondents to participate in the study. The respondents were distributed in various health facilities and designations within Nairobi County. The respondent from these facilities included 50.6 percent from the National Hospital, 36.5 percent from county hospital, 11.8 percent from sub-county health facilities and 1.2 from health centre. The respondents comprised of physicians at different designations with majority (31.4 percent) being medical officers. Figure 4: Distribution of Respondents by Facility and designation 22 Source: Student’s Computation 4.4 Specific Analysis 4.4.1 Influence of training on job satisfaction among physicians The first objective of this study was to establish the influence of training on job satisfaction among physician in public sector of Nairobi. Ten sub-variables under the training variable were considered during this research. These were: Overall, the training I receive on the job meets their needs; training and development are encouraged and rewarded in their department; overall, I am satisfied with the amount of training I receive on the job; their department provides learning/training opportunities to meet the changing needs of their workplace; in their department, people are interested in both personal and professional development; I am generally able to use what I learn in on-the-job training in their job; I feel a sense of pride in doing their job; training has increased the employees’ capacity to adopt new technologies and methods; training is an efficient tool for improving their job satisfaction; training sharpens their thinking ability and creativity in order to take better decision in time. The researcher believed that by targeting these elements of the training a good picture of the importance of training to the determination of its effects on job satisfaction among physicians in public sector of Nairobi could be derived. Figure 5 below takes this information further and 23 presents their weighted average scores. The scores are important in determining how the physicians ranked the importance of each of the ten factors as a determinant the level of training and overall job satisfaction. Figure 5: Mean scores of the determinants of training factor Source: Student computation From the graph, training as an efficient tool for improving job satisfaction and sharpening thinking ability and creativity in order to take better decision in time topped the level of importance with a score of 3.5, followed by feeling a sense of pride in doing job with a score of 3.2, general ability to use what is learnt in on-the-job training and increased the employees’ capacity to adopt new technologies and methods with a score of 3.0, interested in both personal and professional development with a score of 2.8, overall training received on the job meeting the needs and department providing learning/training opportunities with a score of 2.5; training and development being encouraged and rewarded in the departments with a score of 2.4 and overall, satisfaction with the amount of training received on the job with a score of 2.2. These mean scores imply that the physicians agree only two of the ten factors were considered to be important determinants of training for job satisfaction. An interesting outcome is that on average physicians are uncertain on the following six statements and disagree that they are satisfied with the overall training they receive on the job. Looking at the inferential statistics, statistical correlation was used to determine the strength and direction of the relationship between the ten factors determining satisfaction with the level of on job training. To interpret the results of the test of this relationship between the determinants and training, correlation coefficients (r) were considered. In correlation analysis, the values of r range 24 from -1 to +1, with -1 symbolising a perfectly negative relationship and +1 symbolising a perfectly positive relationship. A value of zero (0) for r implies that there is no relationship between the determinant(s) and the variable or that they are independent and not related. Table 4 below shows the correlation coefficients of the ten determinants with respect to training. Table 2: Correlation coefficients of the determinants of training Training Factors pwcorr p-value Overall, the training I receive on the job meets my needs 0.74321 0.0000 Training and development are encouraged and rewarded in my department 0.73636 0.0000 Overall, I am satisfied with the amount of training I receive on the job 0.73550 0.0000 My department provides learning/training opportunities to meet the changing needs of my workplace 0.68090 0.0000 In my department, people are interested in both personal and professional development 0.63379 0.0000 I am generally able to use what I learn in on-the-job training in my job 0.63030 0.0000 I feel a sense of pride in doing my job 0.56527 0.0000 Training has increased the employees’ capacity to adopt new technologies and methods 0.53563 0.0000 Training is an efficient tool for improving my job satisfaction 0.47404 0.0000 Training sharpens my thinking ability and creativity in order to take better decision in time 0.42385 0.0000 Source: Student’s Computation From the analysis shown by table 4, the correlation coefficients for the overall training received on the job meeting the physician needs r = 0.78, Training and development encouraged and rewarded in the department r =0.736, Overall, satisfaction with the amount of training received on the job r =73.5, Department providing learning/training opportunities to meet the changing needs of the workplace r = 0.68, People are interested in both personal and professional development r = 0.633 and general ability to use what is learnt in on-the-job training in the job r = 0.630 have a strong positive relationship with on overall training aspect. Feeling a sense of pride in doing once job r = 0.565 and training increasing the employees’ capacity to adopt new technologies and methods r = 0.535, have moderately strong positive relationship with overall training while training being an efficient tool for improving job satisfaction r = 0.474 and training sharpening thinking ability and creativity in order to take better decision in time r = 423 have a weak positive relationship with on overall training aspect. The ability of training to sharpens thinking ability and creativity in fostering better timely decision making and ability to use the skills at work also scored highly among physicians in public sector of Nairobi. Detailed analysis revealed that factors considered to be very important to the doctors in training had weaker statistical association with job satisfaction and instead; training received at work 25 place, encouragement of training and development and rewarding, satisfaction with amount of training received, provision of opportunities for learning, interest in personal and professional development and ability to apply what is learnt had stronger statistical significance with job satisfaction. Physicians in the county of Nairobi regarded with importance the use of training as an efficient tool for improving job satisfaction a finding similar to that of a research done among UK doctors who raised concerns about the adequacy of the training they received (Maisonneuve, Lambert and Goldacre, 2014). More than 80% of the physicians worked in the County and National referral hospitals which that have been gazetted as the highest referral facilities meant to handle complex clinical patients (MOH, 2014). It then demands that the physicians stationed within these centres have the right skills and knowledge to manage patients. 4.4.2 Influence of job engagement on job satisfaction among physicians The second objective of this study was to establish the influence of job engagement on job satisfaction among physicians. Ten sub-variables under the job engagement variable were considered during this research. These were: Degree of autonomy in their organization enables me value their work thereby inspiring me to even work harder; An organization that allow me feel sense of accomplishments motivate me to even devote more effort in achieving organizational goals ; I am inspired to meet their goals at work; I tend to be committed to a company that respects me as its employee; People are encouraged to take-action once something goes wrong; Communication between employees and senior management is good; Promotions makes me like their job and work harder at their workplace; Recognition about job performance is important to me; I am determined to give their best at work every day and I am satisfied with their overall compensation. Figure 6 below, takes this information further and presents their weighted average scores. These scores are important in determining how the physicians ranked the importance of each of the ten 26 factors as determinants of satisfaction with the level of engagement in determining job satisfaction. Figure 6: Mean scores of the determinants of engagement factor Source: Student’s Computation From the graph, recognition about job performance being important to the physician topped the importance with a score of 4.4, followed by organization allowing them to feel sense of accomplishments motivate them to even devote more effort in achieving organizational goals with a score of 4.3, commitment to a company that respecting them as their employee and promotions makes them like their job and work harder at their workplace with a score of 4.2, Being determined to give their best at work every day with a score of 4.0, People are encouraged to take-action once something goes wrong and degree of autonomy in their organization enables them value their work thereby inspiring them to even work harder with a score of 3.4, Being inspired to meet their goals at work with a score of 3.2, Communication between employees and senior management being good with a score of 2.5 and being satisfied with their overall compensation with a score of 2.0. Overall, the physicians agree with the first five factors, they are uncertain with the following four factors and disagree that they are satisfied with the overall compensation they are given. 27 Statistical correlation was used to determine the strength and direction of the relationship between the all the factors and level of engagement. Table 5, summarises the correlation analysis. Table 5: Correlation coefficients of the determinants of Engagement ENGAGEMENT FACTORS pwcorr p-value Degree of autonomy in my organization enables me value my work thereby inspiring me to even work harder 0.71081 0.0000 An organization that allow me feel sense of accomplishments motivate me to even devote more effort in achieving organizational goals 0.65348 0.0000 I am inspired to meet my goals at work 0.62803 0.0000 I tend to be committed to a company that respects me as its employee 0.62678 0.0000 People are encouraged to take-action once something goes wrong 0.60577 0.0000 Communication between employees and senior management is good 0.55997 0.0000 Promotions makes me like my job and work harder at my workplace 0.54665 0.0000 Recognition about job performance is important to me 0.46117 0.0000 I am determined to give my best at work everyday 0.44794 0.0000 I am satisfied with my overall compensation 0.38428 0.0003 Source: Student’s Computation From the analysis shown by table 5, the correlation coefficients for the degree of autonomy in an organization enabling physician value their work thereby inspiring them to even work harder, r = 0.71, an organization that allow them feel sense of accomplishments motivate them to even devote more effort in achieving organizational goals r = 0.65, Being inspired to meet their goals at work r = 0.628, Committed to a company that respects them as its employee r = 0.626 and people being encouraged to take-action once something goes wrong r = 0.605 have a strong positive relationship with engagement aspect. Communication between employees and senior management being good r = 0.55 and promotions making them like their job and work harder at their workplace r = 0.54 have moderately strong positive relationship with engagement while recognition about job performance being important to them r = 0.46, being determined to give their best at work every day r = 0.44 and being satisfied with their overall compensation r = 0.38 have a weak positive relationship with engagement aspect. The engagement variables; communication, respect, autonomy, sense of accomplishment and promotion had statistically significant associated with job satisfaction. Constant interference with physician autonomy has been reported result in dissatisfaction among physicians (Stoddard et al., 2001). 28 Job characteristic factors such as recognition of performance, accomplishment, respect and promotion highly emerged as important factors which have been reported elsewhere to have a positive cognition effect (Schaufeli and Bakker, 2004). Role clarity- understanding the roles and expectations of an employee can achieved with effective communication. Communication between an employer and an employee affects behavioral aspects of an employee- attitudes, happiness and satisfaction (Burton, Pathak and Zigli, 1976). Communication is critical in developing organizational teams and for individual success as it allows effective delegation and aligning the goals of the departments to the goals of the organization (Proctor, 2014). 4.4.3 Establish the influence of job security on job satisfaction among physicians The third objective of this study was to establish the influence of job security on job satisfaction among physicians. Ten sub-variables under the job security variable were considered during this research. These were: Organization’s financial stability is key towards job security; Employment contract plays an important role in assuring job security; Job security is the most determinant and key element influencing an employee’s decision on whether to join an organization or not; Collective bargaining 4ment enhances job security; Job security has become one of the most crucial and important factors among the employee preference list; Jobs which are not backed by indefinite contract or cannot be guaranteed for reasonable period are deemed to lack job security; Do you see a good career in your choice to pursue medicine as a secure career; Labour and employment laws have been domesticated in the facility you work in and applied; Do you see yourself losing your job in the next 12 months and the likelihood of you finding another job outside public health sector is high. Figure 7 below, takes this information further and presents their weighted average scores. These scores are important in determining how the physicians ranked the importance of each of the ten factors as determinants of job security. 29 Figure 7: Mean scores of the determinants of Job Security Source: Student’s Computation From the graph, organization’s financial stability being key towards determining job security topped with a score of 4.3, this was followed by job security becoming one of the most crucial and important factors among the employee preference list with a score of 4.2, collective bargaining agreement enhancing job security and jobs which are not backed by indefinite contract or cannot be guaranteed for reasonable period deemed to lack security with a score of 4.1, Employment contract playing important role in assuring job security with a score of 4.0, Job security being the most determinant and key element influencing an employee’s decision on whether to join an organization or not with a score of 3.6, the likelihood of them finding another job outside public health sector being high and seeing a good career in their choice to pursue Medicine as a secure career with a score of 3.5, Labour and employment laws being domesticated in the facility they work in and applied with a score of 2.8 and seeing themselves losing their job in 12 months with a score of 2.0. Overall, the physicians agree with the first eight factors, they are uncertain labour and employment laws has been domesticated in the facility they work in and applied and disagree the likelihood of them finding another job outside public health sector is high. Statistical correlation was used to determine the strength and direction of the relationship between factors and job security. Table 6 summarises the correlation analysis. 30 Table 6: Correlation coefficients of the determinants of job security JOB SECURITY pwcorr p-value Organization’s financial stability is key towards job security 0.71307 0.0000 Employment contract plays an important role in assuring job security 0.68396 0.0000 Job security is the most determinant and key element influencing an employee’s decision on whether to join an organization or not 0.66036 0.0000 Collective bargaining 4ment enhances job security 0.55623 0.0000 Job security has become one of the most crucial and important factors among the employee preference list 0.53542 0.0000 Jobs which are not backed by indefinite contract or cannot be guaranteed for reasonable period are deemed to lack job security 0.53275 0.0000 Do you see a good career in your choice to pursue Medicine as a secure career 0.39305 0.0002 Labour and employment laws have been domesticated in the facility you work in and applied 0.28310 0.0083 Do you see yourself losing your job in the next 12 months 0.27639 0.0100 The likelihood of you finding another job outside public health sector is high 0.20328 0.0605 Source: Student’s Computation From the analysis shown by table 6, the correlation coefficients for the organization’s financial stability being key towards job security r = 0.71, employment contract playing an important role in assuring job security r = 0.68, job security being the most determinant and key element influencing an employee’s decision on whether to join an organization or not r = 0.66, collective bargaining agreement enhancing job security r = 0.56, job security has become one of the most crucial and important factors among the employee preference list r = 0.56 and jobs which are not backed by indefinite contract or cannot be guaranteed for reasonable period deemed to lack job security r = 0.53 have a strong positive correlation with job security. Seeing once career as a good choice, and to pursue Medicine as a secure career r = 0.39 moderately strong positive relationship with job security while labour and employment laws being domesticated in the facility they work in and applied r = 0.28, seeing one-self losing their job in the following 12 months r = 0.27 and the likelihood of them finding another job outside public health sector being high r = 0.20 have a week positive relationship with job security. Analysis showed a strong statistical significance of organizational financial stability, contractual agreements, job security as a determinant of turnover and collective bargaining agreement as variables had a stronger correlation with job satisfaction. Employees who work for financially stable organizations are more likely to settle in at their workplace, achieve their goals, plan for retirement and ultimately achieve the goals of their organizations (Zubr et al., 2016) however age 31 is a significant factor that has been reported to influence job tenure and should be considered in employment (ANYANZWA, 2013). 4.4.4 Establish influence of working environment on job satisfaction among physicians. The fourth objective of this study was to establish influence of physical working environment on job satisfaction among physicians. Ten sub-variables under the physical environment variable were considered during this research. These were: I am aware of the risks and hazards in their working environment; Their employer is committed to ensure the health and safety of its employers; I am aware of their personal responsibility in ensuring their safety within their place of work; I am satisfied with current maintenance of the building; I am satisfied with the hygiene maintenance in the Organization; I am Satisfied with Current fixed working hours; The health facility has provision for rest during working hours such as calls; I am satisfied with ventilation within the health facility; People with disability can access the facility easily and I have access to equipment’s that allow me to utilize their skills. Figure 8 below, takes this information further and presents their weighted average scores. These scores are important in determining how the physicians ranked the importance of each of the ten factors as determinants of physical environment affecting their job satisfaction. Figure 8: Mean scores of the determinants of physical environment Source: Student’s Computation 32 From the graph, being aware of their personal responsibility in ensuring their safety within their place of work topped the level of importance with a score of 4.2, followed by being aware of the risks and hazards in their working environment with a score of 4.0, People with disability being able to access the facility easily with a score of 2.7, being satisfied with ventilation within the health facility and their employer being committed to ensuring the health and safety of the employees with a score of 2.3, Being satisfied with the hygiene maintenance in the Organization, the health facility having a provision for rest during working hours such as calls and being satisfied with current fixed working hours with a score of 2.2 and having access to equipment’s that allow them to utilize their skills with a score of 2.1. Overall, the physicians agree with the first two factors, they are uncertain whether people with disability are able to access the facility easily and disagree with all the other factors. Statistical correlation was used to determine the strength and direction of the relationship between the factors and job security. Table 7 summarises the correlation analysis. Table 7: Correlation coefficients of the determinants of physical environment. PHYSICAL ENVIRONMENT pwcorr p-value I am aware of the risks and hazards in my working environment 0.680312 0.0000 My employer is committed to ensure the health and safety of its employers 0.673604 0.0000 I am aware of my personal responsibility in ensuring my safety within my place of work 0.631568 0.0000 I am Satisfactied with current maintenance of the building 0.594716 0.0000 I am satisfied with the hygiene maintenance in the Organization 0.585108 0.0000 I am Satisfied with Current fixed working hours 0.581768 0.0000 The health facility has provision for rest during working hours such as calls 0.577227 0.0000 I am satisfied with ventilation within the health facility 0.478942 0.0000 People with disability can access the facility easily 0.460414 0.0000 I have access to equipment’s that allow me to utilize my skills 0.443689 0.0000 Source: Student’s Computation From the analysis shown by table 7, the correlation coefficients for being aware of the risks and hazards in their working environment r = 0.68, their employer being committed to ensuring the health and safety of their employees r = 0.67, being aware of their personal responsibility in ensuring their safety within their place of work r = 0.63, being satisfied with current maintenance of the building r = 0.59, being satisfied with the hygiene maintenance in the Organization r = 0.58, being satisfied with current fixed working hours r = 0.58, the health facility having provision for rest during working hours such as calls r = 0.57 have a strong 33 positive relationship with the physical environment. Being satisfied with ventilation within the health facility r = 0.47, people with disability can access the facility easily r = 0.46 and having access to equipment’s that allow them to utilize their skills r = 0.44 have a moderately positive relationship with physical environment. Employer commitment to ensuring safety of the physicians in public sector of Nairobi also had a strong statistical significance with job satisfaction. Physicians in the public sector of Nairobi scored highly the ability to recognise risks and hazards in their environment and the awareness of their personal responsibility to ensure their health and safety which is agreeable with previous studies (Alemie, 2012). Recognition of the workplace hazards and mitigation of the same has impact on productivity of the physicians and consequently on provision of care (Vijendren, Yung, and Sanchez, 2015). 4.5 Effects of working environment to job satisfaction among physicians in public sector The purpose of this study was to establish effects of working environment to job satisfaction among physicians in public sector of Nairobi. To achieve this, the research broke down the study into four key objectives: (1) to establish the influence of training on job satisfaction among physicians in public sector of Nairobi; (2) to establish the influence of job engagement on job satisfaction among physicians in public sector in Nairobi; (3) to establish the influence of job security on job satisfaction among physicians in Public sector of Nairobi and, (4) to establish influence of physical working environment on job satisfaction among physicians. Figure 9 below, takes this information further and presents their weighted average scores. These scores are important in determining how the physicians ranked the importance of each of the four factors as determinants of job satisfaction. 34 Figure 9: Mean scores of the factors affecting Job satisfaction among physician Source: Student’s Computation From the graph, the physicians agree that job security was the most important factor with a score of 3.59, followed by the level of employees’ engagement with a score of 3.54. Level of training with a score of 3.45 was third while they were uncertain whether the physical environment (score of 2.6) determine their job satisfaction or not. Statistical correlation was used to determine the strength and direction of the relationship between the four factors and job satisfaction. Table 7, summarises the correlation analysis. Table 7: Correlation coefficients of the determinants of Job satisfaction JOB SATISFACTION pwcorr p-value TRAINING FACTORS 0.8061 0.0000 ENGAGEMENT FACTORS 0.7803 0.0000 JOB SECURITY 0.5720 0.0000 PHYSICAL ENVIRONMENT 0.4953 0.0000 Source: Student’s Computation From the analysis shown by table 7, the correlation coefficients for the level of training r = 0.80, level of engagement r = 0.78 and job security r = 0.57 have a strong positive relationship with job satisfaction. Physical environment r = 0.49 has a moderately strongly relationship with job satisfaction. 35 4.6 Conclusions Training emerges as the factor with the strongest influence on job satisfaction and is therefore the most important to the physicians. This edge over the other factors is marginal though, with engagement following a close second in order of importance. Job security has the third most importance while physical environment is the least important among the four factors influencing job satisfaction. 36 CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.1 Influence of training on job satisfaction among physicians Objective one sought to explore the effects of training on job satisfaction among physicians in public sector of Nairobi. First, this study reports a positive correlation between training and job satisfaction which has been reported elsewhere (Schmidt, 2007). A study done in the UK on the importance of in-job training revealed that training was an efficient tool in improving job satisfaction (Maisonneuve, Lambert and Goldacre, 2014). However even in areas that training was provided, there was no time allocated for the training in the rota which then interfered to take up the training opportunities (Lambert, Smith and Goldacre, 2015). Training has the ability to sharpen the thinking ability and creativity mong physicians fostering timely clinical decision making, the training being in line with the changing art of the practice in medicine that requires that physicians keep up to date with the current innovations as relying on the undergraduate and graduate studies is not sufficient (AL-SHAMSI, 2017). Biomedical innovations continue to change the practice of preventive, promotive, diagnostic, curative and rehabilitative medicine (ESC Board, 2018). However, these factors did not have a strong correlation with job satisfaction. This can be explained by the fact that a good number of physicians strongly agreed that these factors-training as an efficient tool for improving job satisfaction, ability of training to sharpen thinking capacity and a sense of pride doing their jobs- were important while another significant number strongly disagreed. Whereas on weighted average it ranked high in correlation they had a moderate positive strong magnitude on correlation as compared to other factors. On job continuous medical education defined as the training or knowledge acquired after completion of formal training (Davis, 1998) is vital for physicians. Continuous medical education goal goes beyond impacting knowledge to physicians. Studies have shown that continuous medical education influence clinical performance and consequently on patient outcomes in a dynamic field with increased emphasis on quality of care to patients (Cantillon and Jones, 1999). 37 Innovations are changing the face of medicine and require that physicians keep up to date with the growing need to offer quality care to patients. So important in Kenya is continuous medical education that the Kenya Medical Dentist and Practitioners Board has made it mandatory to accumulate at least fifty continuous professional development points for one to renew their licenses annually (KMPDB, 2016). Satisfaction with the offered training is dependent on the relevance indicating that training provided should not only meet the needs of the physicians but should also be relevant (Vakani et al.,2012). In complex environments that require competency to manage patients compounded with shortage of physicians, there is need to constantly capacity build the physicians with knowledge to and met the demand of the masses (AL-SHAMSI, 2017). Continuous medical needed by clinicians should have a mix of clinical and non-clinical modules. This is in line of the need to have clinicians particularly consultants who are either heads of units or heads of health facilities acquire skills such as businesses, management, leadership and team building among other (Bronson & Ellison, 2015). Further continuous medical education also seek to change attitudes and behaviours of physicians (VanNieuwenborg et al., 2016). 5.2 Influence of engagement on job satisfaction among physicians Objective two sought to explore the effects of engagement on job satisfaction among physicians in public sector of Nairobi. Recognition of performance, respect, autonomy and promotion have positive cognition on employees and play an intrinsic motivational role to the physicians and are critical in their clinical resulting in physicians having less absenteeism, fewer turnover an less health-related issues which then improves productivity (Christian, Garza and Slaughter, 2011). Recognition of performance by the health institutions motivates the physicians to improve competency and performance thereby completion of tasks successfully (Schaufeli and Bakker, 2004). Indeed engaged employees find more pleasure in work and perform better (Reijseger et al., 2017). Employees’ acknowledgement and commitment to the organization policies, practices and the structure affect their engagement experience consequently organizations that are responsive to employees have better performance. 38 Autonomy offers clinicians an opportunity to make independent decision regarding patient care, interact adequately and improve the relationship with the patients which ultimately affect patient care (DeVoe et al. 2002). What is being witnessed in the devolved system of government is the continuous interference by politicians on care of patient despite lack of clinical knowledge. Effective communication is critical to employees and in the physician to patient relationship, has been shown to influence the outcome of health (Biglu et al., 2017). Effective communication lacked during the devolution of health among the critical stake holders who are the healh care workers resulted in the industrial unrest experienced (Metcalfe, Chowdhury and Salim, 2015). Studies have demonstrated the need for effective institutional communication as; transparency, performance review, precision, sufficient to result in positive attitudes of employees (Neves & Eisenberger, 2012), (Kacmar et al., 2003). Institutional respect expressed when organizations take a non-authoritarian leadership style and critical components of respect to employees include: shared beliefs, deference as an institutional strength, respect as an institutional matter, equity and recognition of self (Stürmer, Simon and Loewy, 2008). Healthcare is a complex and detailed industry that requires physicians to have focus and energy- engaged employees therefore will inherently express these characteristics which then improves productivity. In an industry that requires rapid decision making due to complexities of health conditions, physicians are constantly called upon to put in that extra hour or push beyond the expected output to save a life; recognition and rewarding of these extra miles intrinsically motivates the physicians to better performance (Abduljawad and Al-Assaf, 2011). 5.3 Influence of Job security on job satisfaction among physicians The third objective sought to explore the influence of job security on job satisfaction among physicians in public sector of Nairobi. Job security emerged as an important influence of decision making to join an institution, the influence of a collective bargaining agreement to influence job security, presence of indefinite contracts and employment contact. With the devolved system of government, the human resource for health function was devolved to the county level by way of seconding the healthcare workers as provided in schedule IV of the constitution of Kenya (Tsofa, Goodman, Gilson, & Molyneux, 2017). The seconding of 39 healthcare workers to the county level (Kenya Constitution, 2010) brought with it multiple challenges among them job insecurity characterized by poor management of resources, poor understanding of the health system, management challenges, lack of proper structures to coordinate health between the two governments and ethnic profiling of physicians with non- natives receiving harsh treatments that consequently have resulted in massive resignation by physicians (Kimathi, 2017). The massive resignation by healthcare workers from Turkana was documented by International Rescue Committee who reported an increased in the natives from previous 52% in 2013 to 92% in 2015 due to the exodus of the healthcare workers (IRC Kenya, 2015) citing fears of ethnic profiling and frustrations experienced resonates with some of the factors that the physicians in public sector cited as reasons for job insecurity. Financial stability of institutions will ensure timely remuneration of the physicians; availability of positive externalities such as medical cover; paid leaves; adequate staff; factors that have influence on turnover findings that have been reported in a study of internal brain drain in Mozambique (Sherr et al., 2012) and the same findings were accounted for among physicians in Portuguese speaking countries who stayed in private practice (Russo et al., 2014). Collective bargaining agreement have been recognized as powerful legal tools of union members to offer job security (Paolucci, 2017). With the devolved system, multiple counties refused to recognize the membership of the physicians to belong to the Kenya Medical Pharmacy and Dentist Union causing fear and uncertainty about the future of their jobs at the county levels. Physicians worrying about the future of the organizations are more likely to have anxiety and stress consequently mental ill-health (De Witte, Vander Elst and De Cuyper, 2015). While it has not been implemented, the Ministry of health has been pushing for contractual engagement of physicians at the county level which are timebound and renewable at the discretion of the counties this decision against previous national policy of permanent and pensionable schemes for all physicians. Temporary contracts have been shown to have negative influence on job satisfaction (Chadi and Hetschko, 2016) the same finding being reflected in a research of temporary contract on job satisfaction among PhD graduates (Waaijer et al., 2017). 40 5.4 Influence of physical working environment on job satisfaction among physicians The common workplace injuries frequently reported include; mental illness (stress, anxiety and depression), substance abuse, needle stick injuries, musculoskeletal injuries, respiratory illness (commonly TB) and nosocomial infections whose risk are accentuated by absence of protective, duration of exposure to the hazard, availability of occupational workplace policy and protective wear (Ndejjo et al., 2015). Despite the recognition of workplace hazards and risks, a research conducted to review the knowledge, attitudes and practices of healthcare regarding Tuberculosis reported that despite the knowledge on transmission modalities of Tuberculosis, the healthcare workers had gaps in uptake of infection control practices (Bhebhe, Van Rooyen and Steinberg, 2014). Further analysis of the physical environment variables in this research revealed that personal responsibility in safety and awareness of the risks and hazard of the workplace had significant statistical relationship with job satisfaction which has been reported (Senthil et al., 2015) despite the physician practices remaining poor (Alemie, 2012). In Kenya, it is a legal provision the responsibility of the employer and in this case the County government of Nairobi to ensure that the safety of the employees is guaranteed at the workplace (KLR, 2007). The physicians of Nairobi scored poorly this variable recognizing the inability of the county government of Nairobi to provide adequate safety interventions within healthcare. High turnover, absenteeism can be decreased by adequately providing to conducive physical environments which ultimately will result in improved job satisfaction and consequently productivity (Mj, Eu and Nm, 2017). 5.5 Recommendation A country categorised by WHO as among those that have a critical need for physicians, it then calls out to government to ensure that the few available are retained. 5.5.1 Practical Implications for decision makers Training emerges as the factor with the strongest influence on job satisfaction and is therefore the most important to the physicians. This edge over the other factors is marginal though, with engagement following a close second in order of importance. Job security has the third most 41 importance while physical environment is the least important among the four factors influencing job satisfaction. Whereas there are appreciable funding deficits for healthcare initiatives, from a strategic perspective, the healthcare leadership at both forms of governments need to prioritize on factors, which have significant implication on job satisfaction- training. Both the findings of this study and of previous studies done have highlighted the effect of training on productivity, performance and ultimately patient outcomes. Arching still on the inadequate resources, the county government of Nairobi together with the national government can leverage on existing development partners to focus on the human resource for health aspect as a critical component of the health system and strengthen that need to be strengthened. Physicians have diverse needs which cannot be addressed by generic training module. This then requires that a needs assessment be carried out to define these needs, identify the gaps that exist for optimum productivity and then prioritize on the areas of need that require immediate interventions. As part of people management, the policy makers should include training as a key performance indicator as they implement the WHO guide of transforming and scaling up education and training (World Health Organization, 2013); Training is a significant variable that influences organizational citizen behaviour by influencing positive attitude towards the organization, building commitment towards organization goals and building healthy relationships that influence the productivity of the organization. With a strong organization citizenry healthcare institution are bound to reap revenue due to presence of committed and productive physicians. The management of human resource for health in Kenya Is informed by policies under the public service management- Civil Service Code of Regulations that lays out the minimums of recruitment, management and development of health workers, this with limited flexibilities to be able to attract healthcare workers to be retained in the public sector and also to have them take up opportunities in the hard to reach areas. The current existing policies that govern human resource for health in Kenya re multiple- the Kenya Vision 2030; Kenya Health Policy Framework 1994-2010; NHSSP II 2005-2010 and 42 KEPH; Health Ministries Strategic Plans; Ministerial Annual Operation Plans- which are disjointed and lack clarity in addressing the issues facing human resource for health in Kenya. The government should support a National constitutional framework to address the numerous issues affecting the health workforce- Health Service Commission The current management for human resource for health under devolution has and continues to face multiple challenges. Borrowing the model of the Kenya Teachers Service commission that is entrenched in the constitution of Kenya (TSC, 2010) which manages the human resource among all teachers in Kenya and which is entrenched in the constitution of Kenya of 2010 is recommended. These centralized body will design and implement context-specific attraction and retention policies unique to the health sector, ensure compliance with Occupational Safety and Health ACT of 2007, develop a competency framework for healthcare workers and advocate for development of a performance contracting management system. 5.6 Suggestions for further research This research focused on only four factors, which despite their strength did not disaggregate the data according to gender and age. While the respondents were gender balanced, future research can consider looking intrinsically into these components of working environment and how they affect job satisfaction among women. 43 6.0 References Devolved Government - Kenya Law Reform Commission (KLRC). (n.d.). 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APPENDICES Appendix I: Cover Letter Dear respondent, RE: Questionnaire for Academic Project It is my request that you fill in the attached questionnaire on the research that I am carrying a study on assessing the effect of working environment on job satisfaction among physicians in public sector of Nairobi County. Your effort in filling the questionnaire will be highly appreciated since it will be a fulfillment for the awarding of my Master’s degree in Business Administration in Healthcare management from the Strathmore University. Information that you provide will be handed with utmost confidentiality and personal details will not be referred to anywhere in my research project. 53 Thank you and be bless. Yours Sincerely, Stellah Bosire APPENDIX I1: QUESTIONNAIRE GENERAL INFORMATION 1. Indicate your gender Male Female 2. What is your age in years? 20-30 years 31-40 years 41-50 years 51 - 60 years Over 60-70 years 3. What is your highest level of education? • Post graduate -Diploma • Degree • Masters • Doctorate • Others (Specify)_______________ 54 4. How long have you worked for the county? Below 1 year 1 – 2 years 2 – 3 years 3 - 4 years Above 4 years • Which department do you work in National Hospital County hospital Sub-County (Specify) Health-Centres ______________________________________________________ a. What is your designation/title? ______________________________________________________ SECTION 2: WORK ENVIRONMENTAL FACTORS B: TRAINING FACTORS Please indicate by circling the appropriate box the extent to which you agree or disagree with each of the statements below. The following scale is applied for all statements Where 1= Strongly Disagree (SD); 2= Disagree (D); 3=Uncertain (N); 4= Agree (A); 5=Strongly Agree (SA) Statements S tr o n g ly D is a g re e D is a g re e U n ce rt a in A g re e S tr o n g ly A g re e 1 My department provides learning/training opportunities to meet the changing needs of my workplace 2 Training sharpen my thinking ability and creativity in order to take better decision in time 55 3 In my department, people are interested in both personal and professional development. 4 Training is an efficient tool for improving my job satisfaction 5 I feel a sense of pride in doing my job 6 Overall, the training I receive on the job meets my needs 7 Training has increased the employees’ capacity to adopt new technologies and methods 8 Training and development are encouraged and rewarded in my department 9 I am generally able to use what I learn in on- the-job training in my job 10 Overall, I am satisfied with the amount of training I receive on the job C: ENGAGEMENT FACTORS Please indicate by circling the appropriate box the extent to which you agree or disagree with each of the statements below. The following scale is applied for all statements Where 1= Strongly Disagree (SD); 2= Disagree (D); 3=Uncertain (N); 4= Agree (A); 5=Strongly Agree (SA) Strongly disagree (1) Disagree (2) Neither agree nor disagree (3) Agree (4) Strongl y Agree (5) Communication between employees and senior management is good I tend to be committed to a company that respects me as its employee Degree of autonomy in my organization Enables me value my work thereby inspiring me to even work harder 56 An organization that allow me feel sense of accomplishments motivate me to even devote more effort in achieving organizational goals Promotions makes me like my job and work harder at my workplace Recognition about job performance is important to me People are encouraged to take-action once something goes wrong I am inspired to meet my goals at work I am determined to give my best at work everyday I am satisfied with my overall compensation D: JOB SECURITY Please indicate by circling the appropriate box the extent to which you agree or disagree with each of the statements below. The following scale is applied for all statements. Where 1= Strongly Disagree (SD); 2= Disagree (D); 3=Uncertain (N); 4= Agree (A); 5=Strongly Agree (SA) 1 2 3 4 5 Statements S tr o n g ly D is a g re e D is a g re e U n ce rt a in A g re e S tr o n g ly A g re e 1 Job security has become one of the most crucial and important factors among the employee preference list 57 2 Jobs which are not backed by indefinite contract or cannot be guaranteed for reasonable period are deemed to lack job security 3 Do you see yourself losing your job in the next 12 months 4 Do you see a good career in your choice to pursue Medicine as a secure career 5 Job security is the most determinant and key element influencing an employee’s decision on whether to join an organization or not 6 Employment contract plays an important role in assuring job security 7 Collective bargaining agreement enhances job security 8 Organization’s financial stability is key towards job security 9 Labour and employment laws have been domesticated in the facility you work in and applied 10 The likelihood of you finding another job outside public health sector is high E: PHYSICAL ENVIRONMENT Please indicate by circling the appropriate box the extent to which you agree or disagree with each of the statements below. The following scale is applied for all statements Where 1= Strongly Disagree (SD); 2= Disagree (D); 3=Uncertain (N); 4= Agree (A); 5=Strongly Agree (SA) Statements S tr o n g ly D is a g re e D is a g re e U n ce rt a in A g re e S tr o n g ly A g re e 1 I am aware of the risks and hazards in my working environment 2 My employer is committed to ensure the health and safety of its employers 58 3 I am aware of my personal responsibility in ensuring my safety within my place of work 4 I am Satisfaction with current maintenance of the building. 5 I am satisfied with the hygiene maintenance in the Organization. 6 I am Satisfied with Current fixed working hours. 7 The health facility has provision for rest during working hours such as calls 8 I am satisfied with ventilation within the health facility 9 People with disability can access the facility easily 10 I have access to equipment’s that allow me to utilize my skills