UNIVERSITY OF MALAWI

COLLEGE OF MEDICINE

Improving Nurse Retention: Factors Influencing Job Satisfaction of All Cadres of Nurses in Machinga District.

BY

MTENGEZO JACINTA
BSc. (Nursing Education)

Dissertation Submitted in Partial Fulfillment of the Requirements of the Master of Public Health Degree

June, 2008

CERTIFICATE OF APPROVAL
The thesis of Jacinta Mtengezo is approved by the Thesis Examination Committee

______________________________ (Chairman, Postgraduate Committee)

______________________________ (Supervisor)

______________________________ (Internal Examiner)

_____________________________ (Head of Department)

DECLARATION
I Jacinta Mtengezo hereby declare that this thesis is my original work and has not been presented for any other awards at the University of Malawi or any other University.

Name of Candidate

Jacinta T. Mtengezo

Signature

_____________________

Date

20 June, 2008

ii

ACKNOWLEDGEMENT

I wish to thank Professor C. Bowie and Mr. F. Maseko, my academic Supervisors and Mrs S. Bandazi my Service Supervisor for their untiring assistance, guidance, efforts, perseverance and constructive suggestions throughout this dissertation process. I also thank Dr. Amos Nyaka and research assistants who assisted with data collection, the participants willingness to be interviewed, Machinga DHO for funding this study, Mr. G.T. Mwenye-phiri, the statistician for guidance in data analysis and MOH for sponsoring me.

Lastly, my gratitude should go to my family members for their encouragement, understanding and support during the entire period of my study.

All readers, this is for you.

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ABSTRACT
Introduction: Increasing job satisfaction is important for job retention. District Health Management Team (DHMT) needs to create environments that attract, motivate and retain nurses in a district. The aim of this study was to explore factors that influence nurses job satisfaction and retention in Machinga District. Methodology: This study was both quantitative and qualitative. Firstly, self-

administered anonymous questionnaires were distributed to all 61 nurses working in Machinga District. Then a qualitative study was done by conducting 3 focus group discussions. Results: Nurses job satisfaction was influenced by social relationships (good interpersonal relationship and support during bereavement) and a clean physical environment. Dissatisfying factors were bad attitudes of the DHMT and health workers, and poor working conditions (workload, lack of resources, incentives, health centre allocation, poor transport and communication network). Nurses could be retained in Machinga District if working conditions were improved in terms of: salary, resources, accommodation, toilets, water, electricity, communication, leadership skills, and transport. Conclusion: Nurses could be retained in the district by providing both monetary and non-monetary incentives at all levels. Therefore, the DHMT should look into these factors in order to attract and retain nurses in the district.

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TABLE OF CONTENTS
Certificate of Approval Declaration Acknowledgement Abstract Table of contents List of Tables List of Figures Abbreviations and Acronyms CHAPTER 1.0 1.1 1.2 1.3 1.4 1.5 1.6 INTRODUCTION i ii iii iv v vii ix x 1 1 5 6 7 9 9

Job satisfaction Job dissatisfaction Shortage of health workers in Malawi Attraction and retention strategies in Malawi Situation analysis of Machinga District Nursing situation in Machinga

CHAPTER 2.0 2.1 2.2

OBJECTIVES OF THE STUDY

13 13 13

Broad Objective Specific Objectives

CHAPTER 3.0 3.1 Introduction

METHODOLOGY

14 14

3.2 3.3 3.4 3.5 3.6 3.7

Research design Study Setting Sampling technique Data collection Data analysis Limitations

14 14 14 15 16 16

CHAPTER 4.0 4.1 4.2 Introduction

RESULTS

18 18 18 18 20 21 23 24 25 25 25 28 30 30 31

Quantitative Results 4.2.1 Demographic Characteristics

4.2.2 Choice of Nursing as a career 4.2.3 4.2.4 4.2.5 4.2.6 4.3 Factors satisfying or dissatisfying nurses Perceptions of nurses towards nursing as a career Factors for job satisfaction and retention Summary of major findings of quantitative data

Focus Group Discussion Results 4.3.1 Factors satisfying nurses 4.3.2 Factors dissatisfying nurses 4.3.3 4.3.4 4.3.5 Factors that can retain nurses Summary of FGD Results Summary of main results of study

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CHAPTER 5.0 5.1 5.2 5.3 5.4 Introduction Job satisfaction

DISCUSSION

32 32 32 33 37

Job dissatisfaction Perceptions on nursing as a career

CHAPTER 6.0 6.1 6.2 Conclusion

CONCLUSION AND RECOMMENDATIONS

39 39 39 39 39 40 40 40 41

Recommendations 6.2.1 Research

6.2.2 Practice 6.2.3 6.2.4 6.2.5 DHMT MOH Professional Development

6.2.6 Education

REFERENCES APPENDICES Appendix one- Quotes of qualitative data Appendix two- Self administered questionnaire Appendix three- Question guide Appendix four- Letters of permission

42 45 45 48 53 54

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LIST OF TABLES
Table 1. 2. 3. 4. 5. Total number of nurses in Machinga District The attrition of nurses in Machinga District Demographic characteristics of nurses in Machinga District Nursing as a first choice career Reasons for joining Government health facilities Page 10 11 19 20 21

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LIST OF FIGURES
1. 2. Hierarchy of needs What brings dissatisfaction for working in Machinga District 5 22

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ABBREVIATIONS AND ACRONYMS

AIDS BLM CHAM DA DFID DHMT DHO DHRMD EN/M FGD HIV MOF MOH NMT RN/M Acquired Immune- Deficiency Syndrome Banja La Mtsogolo Christian Health Association of Malawi District Assembly Department for International Development District Health Management Team District Health Officer Department of Human Resource Management and Development Enrolled Nurse Midwife Focus Group Discussion Human Immunodeficiency Virus Ministry of Finance Ministry of Health Nurse Midwife Technician Registered Nurse Midwife

CHAPTER 1.0

INTRODUCTION

This chapter gives background to the study. It covers literature reviewed in relation to this study that is job satisfaction, dissatisfaction, shortage of health workers, attraction and retention strategies of health workers in Malawi, situation analysis of Machinga District and staffing levels of nurses in Machinga District.

1.1

Job Satisfaction

Job satisfaction is defined as an employees affective reaction to a job based on comparing actual outcomes with desired outcomes [1]. It is generally recognised as a complex construct that includes employee feelings about a variety of both intrinsic and extrinsic job elements. Further it was expressed that employees expect their jobs to provide an accumulation of features (e.g., pay, promotion, autonomy) for which the employee has certain preferential values. The range and importance of these values vary across individuals, but when the accumulation of unmet expectations becomes sufficiently large, job satisfaction is lower and there is a greater probability of withdrawal behavior [2]. Studies have shown that numerous factors influence job satisfaction and these include: duty roaster, type of work, work climate, supervision, interpersonal relationships, status, autonomy, repetition of duties, the nature of tasks to be performed and job outcomes [1,2]. Studies have further indicated that job satisfaction is influenced by ones feelings or state-of-mind regarding the nature of the work, quality of ones relationship with the supervisor, the quality of physical environment in the work place and the degree of fulfillment in the work [3, 4]. Increasing job satisfaction is

important for its humanitarian value and for job retention. Satisfaction and retention have always been important issues for employers seeking better job performance.

However, a study done by Mackintosh [5] in relation to job satisfaction and retention indicated that retention strategies need to be looked at differently in every health facility. Job satisfaction comprises positive and/or negative attitudes held by individuals in respect to their job. Not only does it influence good employee performance, it also maintains good employee health and longevity. Managers need to show employees that they are valued and therefore treat them with respect and like professionals. They also need to build organizational commitment among their employees by involving front line managers in planning and decision making; creating and supporting opportunities for professional development and growth; and showing their appreciation to those on the front-line.

In order to increase job satisfaction, the focus should be on: professional support and recognition, balanced workload, appropriateness and quality of technical equipment, material resources and physical work environment and nurses participation in hospital affairs [6]. It was further stressed that in order to increase the number of nurses having the firm intent to stay, emphasis should be on professional development opportunities and improve scheduling, team dynamics, leadership and communication.

Job satisfaction has also been determined by personal action or characteristics like gender, age, marital status, education, productivity and income relative to the comparison group [7]. This comparison can also be individuals comparison of their

present job with the benchmark opportunities open to them. The work characteristics (routine, autonomy and feedback), characteristics of how the work role is defined (role conflict and role ambiguity) and characteristics of the work environment (leadership, stress, advancement opportunities and participation) are important in relation to nurses job satisfaction [8]. Clark [9] indicated that job satisfaction has both external and internal context factors. External factors that affect job satisfaction comprise a competitive salary and additional rewards such as release from work due to family matters, flexible work schedule and child raising support. It was further indicated that extrinsic work values such as, job security, salary, fringe benefits and work schedules are also considered to be important in job satisfaction. Restrictions in scheduling and limited availability of time off promote frustration and dissatisfaction. These could be factors that are controlled by external forces and directly affect internal employee satisfaction, such as adequate working hours and workload, stable working environment and support from administration. The internal factors have more influence on employee career satisfaction and motivation which drive an individual to action.

Motivation is the psychological feature that arouses an individual to act toward a desired goal [10]. Motivation directs and energises behaviour for action to satisfy a need. It is important to understand what drives people to initiate action and what influences their choice of action. There are many motivation theories that explain motivation at work. Winslow Taylor (1856 1917) put forward the idea that workers are motivated mainly by pay [10]. Elton Mayo (1880 1949) believes that workers are not just concerned with money but could be better motivated by having their social needs met whilst at work. He introduced the Human Relation School of Thought, which focused on

managers taking more of an interest in the workers, treating them as people who have worthwhile opinions and realising that workers enjoy interacting together [10].

Abraham Maslow (1908 1970) along with Frederick Herzberg (1923) introduced the Neo-Human Relations School in the 1950s, which focused on the psychological needs of employees [10]. Maslow put forward a theory that there are five levels of human needs which employees need to have fulfilled at work. All of the needs are structured into a hierarchy (see figure 1below) and only if a lower level of need is fully met, will a worker be motivated by the opportunity of having the next need up in the hierarchy satisfied. For example a person who is dying of hunger will be motivated to achieve a basic wage in order to buy food before worrying about having a secure job contract or the respect of others. Incentives should be given to workers in order to help them fulfill each need and thus to progress up the hierarchy. Managers should also recognise that workers are individually different, not all of them are motivated in the same way and that not all move up the hierarchy at the same pace. They may therefore have to offer a slightly different set of incentives from worker to worker and place to place.

Recognitio n

Social needs -interaction through provision of teabreaks and lunch

Safety needs -protection and security (work conditions and environment) - provision of equipment and supplies

Physiological needs Enough salary to buy food, pay water, electricity bills and house rent

Figure1: Modified Maslow Hierarchy Of Needs. Source [10]

1.2

Job Dissatisfaction

A study done by Irvine and Evans [11] on job satisfaction and turnover among nurses revealed that dissatisfied employees often show an unreliable work ethic, including taking unscheduled days off, sluggishness in their work and aggression towards other workers or patients, absenteeism, expression of grievances and turnover. Poor working conditions, lack of career structure and lack of job satisfaction also contribute to poor

retention [6]. Shields and Wards [7] in their study on the impact of job satisfaction on intentions to quit explained that those individuals who report dissatisfaction with their job, are 65% overall more likely to hold an intention to quit than those who reporting to be satisfied. A study on identifying factors for job motivation of rural health workers in North Viet Nam found out that those rural doctors were less satisfied with their job than those working in cities [12]. Besides, those who worked individually were less satisfied with their work than group practice. Another study on job satisfaction, psychology, morbidity and job stress among New Zealand general practitioners found out that the main causes of dissatisfaction were: too much bureaucracy and restrictions, health care reforms, long working hours and work by the telephone [13].

1.3

Shortage of Health Workers in Malawi

Malawi is among many other countries that have been affected by a brain drain of health workers. The African continent is facing a health crisis occasioned by very low funding of health services and deterioration of health service infrastructure [14]. These factors together with the brain drain threaten work performance of health workers and job satisfaction. The loss of health workers has significant economic as well as replacement consequences which include high cost and time taken to train qualified and licensed staff [15]. This shortage of health workers in Malawi has been at a crisis point for at least the past decade. Malawi Health Facility Survey [16] found out that 15 of the 26 districts had less than 1.5 nurses out of the established number of two per health facility, while five districts had less than one nurse per facility. Needs Assessment Study report indicated that the overall vacancy rate was 24% with nursing vacancy at 55% which meant that of 6102 established nursing positions, 3356 were vacant [17].

Many reports have indicated that several factors contribute to these shortages, including poor working conditions, low output at training institutions, high failure rates on nursing exams, movement to other occupations, noncompetitive pay, migration to other countries (primarily the UK) and the HIV/AIDS pandemic, which has been blamed for a death rate among Malawis health workers of up to 2% per annum [18, 19, 20]. It was further revealed that health workers meet challenges such as: inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a stimulating work environment, inadequate supervision, poor access to continued professionals training, limited career progression, lack of transparent recruitment and discriminatory remuneration [21]. Disparities in incentives and remuneration among health facilities also contribute to internal migration [22]. These challenges eventually become push factors.

1.4

Attraction and Retention Strategies in Malawi

Many studies and strategies have been done in relation to this so as to retain health workers in Malawi. Despite the increasing levels of migration of health professionals from Malawi which have caught international attention, many continue to serve in the country. The Ministry of Health, in 2004 with external partners developed an effective joint Programme of Work to implement an Emergency Human Resource Programme aiming to double the number of nurses and triple the number of doctors in Malawi's public health service [23]. The aim was to re-employ trained Malawian nurses and clinical officers as well as retaining staff already in the service. It is estimated that 800 or more registered nurses who have left the profession are potentially available in

Malawi for re-recruitment. In its emergency recruitment drive the MOH recruited 570 staff between July and December 2005 with another 600 posts approved by Department of Human Resource Management and Development (DHRMD) and Ministry of Finance (MOF). A Tracer Study conducted by the Health Service Commission in 2006 located over 460 nurses, 160 Clinical Officers and 112 Medical Assistants who had retired or resigned from government service. Out of these, 600 indicated their willingness to return to government service [24]. The recruitment gala in the same year, recruited 465 health workers and less than 300 actually reported for service [24].

Customer satisfaction is the key to retaining customers, satisfaction with job and career choices are important for keeping nurses on the job [25]. Keeping the right staff is a key challenge for health policy makers. In order to attract and retain increased numbers of essential health workers, in March 2005, the government provided a 52% salary increase for 11 cadres, or staff categories, including nurse tutors. Health workers received another salary increase in 2006, which doubled the salary of higher-level health workers. The Government revised the mandatory retirement age from 55 to 60 years, engaged retired nurses and clinicians on a local contract and introduced incentive packages for tutors and other professional health workers deployed at difficult-to-reach remote health facilities which included: meals for night staff, allowances to staff in remote area, promotions and opportunities for further education and enforced retention policies for trainees by putting in place the bond system so that they work in Malawi for 3-5 years [23]. A study on survival and retention strategies for Malawian health professionals, it was found that health workers utilized other survival and retention strategies like reliance on per diems/ allowances from workshops and seminars [26].

1.5

Situation Analysis of Machinga District

Machinga HMIS report [27] indicated that Machinga had a total population of about 440, 500. It is in the southern region of Malawi and is bordered to the west by Balaka, Mangochi to the north, to the south by Zomba and to the east by Mozambique. The district had 12 traditional authorities. There were 23 Health Centres, five of which were Christian Health Association of Malawi (CHAM) facilities, one under Banja La Mtsogolo (BLM) and one under the District Assembly (DA). The district hospital had an official total bed capacity of 229 but additional beds were squeezed in making an actual total of 253. Like many parts of the country, Machinga had a high prevalence of HIV/AIDS of about 11.9% [28]. This increased the total number of patients that were admitted at the hospital due to HIV/AIDS problems. The average number of patients at the hospital per day was 500 against 6 nurses per shift in 7 wards. This meant that one nurse looked after 83 patients in the ward and there was no nurse in one ward. This showed critical shortage of nurses compromising nursing care. The nurses needed to be retained in the district and also to attract more to join the service in order to provide quality care.

1.6

Nursing Situation in Machinga From July 2001-June 2006

Machinga HMIS reports [27] and data in District Nursing Officers office [29] indicated that the nursing situation had been fluctuating for both Registered Nurses/Midwives (RN/M), Enrolled Nurses/Midwives and Nurse Midwives Technicians (EN/M, NMT) as follows:

Table 1: Total number of nurses in Machinga district for Government, CHAM and Private Health facilities
GOVERNMENT CHAM/ PRIVATE PERIOD TITLE ESTABLI SHMENT July 2001June 2002 July 2002June 2003 July 2003June 2004 July 2004June 2005 July 2005June 2006 RN/M EN/NMT RN/M EN/NMT RN/M EN/NMT RN/M EN/NMT RN/M EN/NMT 23 102 23 102 23 102 23 102 23 102 NUMBER FILLED 7 31 8 34 8 30 6 49 6 56 30 30 35 33 35 29 26 48 26 55 0 5 0 9 0 10 0 12 1 15 78 77 48 51 43 % FILLED NUMBER DISTRICT TOTAL

From table 1, most posts were not filled and the vacancy rate for government health facilities was 50%. Also the number of nurses working in Machinga District (CHAM, Private and Government) health facilities had been fluctuating between 43 and 78 since 2002. In 2006, Out of the 78 nurses, 17 were at nursing and midwifery training colleges for upgrading. This meant that 61 were working in the district. With a total population of 440,500 in the district, this meant that 1 nurse looked after a population of about 7,000. This ratio (1:7,000) is too high as compared to the African average of 1:1000

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[18]. Based on African average ratio, Machinga District needs 440 nurses. Due to this shortage of nurses, the hospital has reorganized care delivery into 2 work shifts that is from 7.30 am to 5.00 pm and from 5.00 to 8.00 am yet little is known about the effects on nurses role, stress and career satisfaction.

Staff turnover between 2002 and 2006 had been high as shown in table 2 below: Table 2: The attrition of nurses in Machinga district for government health facilities
PERIOD DEATHS RESIGNATION/ ABSCONDEES July 2001-June 2002 July 2002-June 2003 July 2003-June 2004 July 2004-June 2005 July 2005-June 2006 TOTAL 2 1 3 1 2 9 3 3 2 1 3 12 5 4 5 2 5 21 TOTAL

From table 2, there was high staff turnover. The district lost 21 nurses in-between 20012006 and 43% were due to deaths and 57% resignations or absconders. Despite strategies to retain and motivate them such as: provision of tea and bread for night staff, locum work for those who are off duty so as to relieve pressure for the few nurses and enhance take home pay, provision of transport from health centres for shopping in Zomba, recognition of best nurse of the year and giving hardship allowance of 4 nights each per month to those in remotest areas. There was still high levels of staff turnover, absenteeism (physical absenteeism and on duty but not performing), nurses refused transfers to health centres, reported late for duties and knocked off early. Disciplinary measures were instituted with little effect. This was a sign of job dissatisfaction as

11

satisfied workers tend to be more creative and become dedicated to their duties. Therefore, this was operational study that looked into factors that influenced job satisfaction of nurses in the district and develop strategies to retain them in the district. >From the reviewed literature, several issues have emerged on retention and job satisfaction. Job satisfaction is influenced by adequate working hours and workload, stable working environment, support of administration, work characteristics (routine, autonomy, and feedback), characteristics of how the work role is defined (role conflict and role ambiguity) and characteristics of the work environment (leadership, stress, advancement opportunities and participation). These retention strategies need to be implemented by individual nurses, DHMT and MOH.

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2.0
2.1

OBJECTIVES OF THE STUDY

Broad Objective The main objective of this study was to explore factors that influence job satisfaction and retention of nurses in Machinga District.

2.2

Specific Objectives The Specific objectives of the study were as follows: To identify factors that satisfy or dissatisfy nurses To identify nurses perception towards nursing as a career To identify factors that can be utilized to increase nurses retention.

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CHAPTER 3.0

METHODOLOGY

3.1

Introduction

This chapter describes the design, setting, sampling technique, data collection procedure, data analysis procedure, ethical consideration and method of dissemination of findings.

3.2

Research Design

The study was both quantitative and qualitative, comprising of focus group discussions and self-administrated anonymous questionnaires.

3.3

Setting

The study was conducted in Machinga District in all its CHAM, Private and Government health facilities in January, 2007.

3.4

Sampling Technique

The district was chosen purposively as the researcher was working in the same district for easy implementation of the findings to help retain the available nurses in the district. All registered and enrolled nurses serving in the district were study subjects; therefore sample size calculation was not done as the sample population in the district was too small for sampling exercise.

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3.5

Data Collection

Data collection was done through survey and FGD. The questionnaire and a question guide were designed by the researcher. Then a pilot study was conducted using 4 nurses from Balaka District to see if the questions could be answered, relevance of the tool and to test the capabilities of the interviewer. The piloted responses were excluded from the study results. The study tool was adjusted and was administered to 61 nurses in the district by two enumerators from Balaka Hospital. This was a self-administered anonymous questionnaire. The permission to carry out the study was sought from the Balaka DHO for the pilot study and Machinga DHO as a study site. Individual nurses were requested to participate in the study but it was emphasized that participation was voluntary and anonymous. The subjects were advised not to write down their names on the questionnaires, thus ensuring anonymity and confidentiality of the study. The

purpose of the research study was communicated to the nurses, who were assured that the questionnaires were to be treated with confidentiality and the information was to be used for policy change so as to help retain nurses in the district. No rewards or monetary incentives were given to participants included in this study.

The survey was conducted first to get individual views on job satisfaction. This helped to explore individuals subjective feelings, thoughts, beliefs and perceptions towards their job satisfaction on nursing as a career without influence from focus group discussions hence controlling exposure bias. Then a qualitative study was done by conducting focus group discussions to see if the answers were similar to those found in the questionnaire survey by using a question guide. Three focus group discussions were conducted comprising of 4 male nurses and 6 female nurses separately to avoid male

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dominance over women and 6 CHAM nurses in order to compare the results in CHAM and Government health facilities. During discussions, a tape recorder was used and follow up questions were posed to clarify issues. The District Health Officer (DHO) of Machinga guided the discussions and two research assistants took notes of the group agreements. The investigator was separated from the rest of the groups in the

discussions to avoid influencing the results as she was the matron of the hospital.

3.6

Data Analysis

Data from the questionnaire survey was analyzed by using SPSS version 12.0 to compute frequencies and percentages. Focus group discussions (FGDs) were recorded by tape and were transcribed after the data collection process. Then data was summarized on master sheets according to the type of response. The data collectors discussed the data with each other and perceptions of interviewees were identified and reported. The discussions were analysed by coding the main themes as expressed by the participants using content analysis. Data was first ordered by marking relevant data relating to the same theme and then summarized by coding the data belonging together in terms of thematic areas. Then, it was further condensed so that it answered the research question.

3.7

Limitations of the study

The following limitations were noted: The study focused on those who were currently working in Machinga District and did not consider those who had left.

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Lack of generalisation of the results to all nurses in Malawi as the sample was only from one district where the results would be applied.

The questionnaire should have included a question for the respondents to indicate whether they are from the District hospital or health centre for comparisons of responses.

Sample size calculation was not done as the population of the nurses in the district was too small for sampling exercise.

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CHAPTER 4.0

RESULTS

4.1

Introduction

The purpose of this study was to explore factors that would influence job satisfaction and retention of nurses in Machinga District. The following findings have been presented: summary of quantitative results, major findings of quantitative results, focus group discussion results, and lastly major findings of the study have been summarised.

4.2

Results of Quantitative Study

4.2.1

Demographic Characteristics

All 61 nurses in the district answered the questionnaire (100% response rate). The selected demographic variables of the participants were related to sex, age, marital status, cadre, employer and years of working experience, which are listed in table 3 below:

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Table 3: Selected demographic characteristics of nurses in Machinga n=61 (100%)

CHARATERISTIC SEX Female Male No response AGE IN YEARS Under 30 31-45 46-59 Over 60 No response Mean age Std. Deviation MARITAL STATUS Married Other NURSES CADRES NMT EN/M RN/M No response EMPLOYER Government CHAM BLM District Assembly YEARS OF WORKING EXPERIENCE Less than 5 6-19 Over 20 Average working experience Std. Deviation 23 (40) 14 (25) 20 (35) 14 years 12.32 47 (77) (13) (8) (2) 28 (46) 21 (34) 7 (12) 5 (8) 21 (34) 40 (66) 18 (30) 18 (30) 13 (21) 7 (11) 4 (8) 39 years 13.34 52 (85) 7 (12) 2 (3) N (%)

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Most of these nurses were females (85%), under 45 years (60%), single headed families (66%) and 77% were government employees. The majority of the nurses (80%) were NMT and EN/M. Ninety-five percent of the subjects had their age between 26 and 52 years and work experience of between 2 and 27 years.

4.2.2 Choice of Nursing as a Career Nurses were asked to indicate if nursing was their first choice career. Below were the results: Table 4: Nursing as a first choice career
Valid Frequency Valid yes no Total 3 45 13 61 Percent 4.9 73.8 21.3 Percent 4.9 73.8 21.3 Cumulative Percent 4.9 78.7 100.0

Most of the nurses (74%) indicated that nursing was their first choice. The main reason for choosing nursing as a career was: to help the sick (73%). Other reasons included: interesting career (19%), job availability (4%), white uniform (2%) and was forced by parents (2%). When asked whether they would choose nursing again, 87% said yes while 10% said no, and 3% gave no response. In addition, when asked if they would recommend choice of nursing to a relative or friend as a career, 72% said yes, 23% said no, while 5% did not respond

Twenty-one percent of the nurses indicated that nursing was not their first choice career. The main reason for not choosing nursing as a first choice career was: low salary (38%).

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Other reasons included: dislike people dying (19%), hours that nurses work (13%), putting on uniform (6%), female career (6%), lack of career guidance (6%), demoralizing career (6%), personally disliking it (6%) and 5% gave no response to the question.

4.2.3

Objective 1: Factors Satisfying or Dissatisfying Nurses

A.

Factors Satisfying Nurses

When asked why the nurses joined government, the following were their responses: Table 5: Reasons for joining government health facilities in order of priority
Valid Reasons Valid job security good career path good collaboration only job available Total Frequency 13 24 15 Percent 21.3 39.3 24.6 Percent 21.3 39.3 24.6 Cumulative Percent 21.3 60.7 85.2

8.2

8.2

93.4

4 61

6.6 100.0

6.6 100.0

100.0

Nurses joined government health service because of job security (39%) and good career path (25%). Other reasons were good collaboration (8%) and only job available after retiring from CHAM (7%).

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B.

Factors Dissatisfying Nurses

Nurses were asked about factors that dissatisfied them while working in Machinga District. Below were the responses:

35 30 Percentage 25 20 15 10 5 0 Bad attitudes of DHMT Bad attitudes of Health Workers Patients are demotivating Lack of resources Workload Series1

Factors

Figure 2: What brings dissatisfaction for working in Machinga District.

From the graph above, 49% of the nurses were dissatisfied working in Machinga because of bad attitudes (27% was bad attitudes of health management team and 22% of health workers), workload 22%, lack of resources and equipment (11.5%). Very few indicated that patients were demotivating and demanding as they always talked bad of nurses (4%).

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4.2.4

Objective 2. Perceptions Of Nurses Towards Nursing As A Career

A.

Choice of Nursing

After working as nurses, 10% of them would not have chosen nursing as career on that day due to: workload (25%), infections (25%), low salary (25%), more working hours (17%) and working while sick (8%).

B.

Future Plans of Nurses on Nursing as a Career

The nurses were asked on their future plans on nursing as a career. Almost half of the nurses (53%) showed interest to work in government and 26% had intentions of leaving the government. Twenty-five percent of those who showed interest to work in government, 25% of them opted to continue serving the government, 23% opted to retire and work month to month and 5% to resign in CHAM and join government. For those who had intentions of leaving government, 21% opted to resign and join other non-governmental organizations while 5% opted to retire and rest at home. 21% did not respond to the question.

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4.2.5

Objective 3. Factors That Could Be Utilised To Ensure Job Satisfaction and Retention

A.

Job Satisfaction

For the nurses to be satisfied with their work, they had recommendations for the fellow health workers, DHMT and MOH. They wished the DHMT improved on working conditions: resources, accommodation, toilets, water, electricity, communication, leadership skills, and transport (62%) and the health workers to work as a team and help each other in terms of problems (35%). The MOH to increase salaries (55%) and train more nurses (15.8%). Less common responses included; introduce risk allowance, introduce exchange visits with other nurses outside Malawi, introduction on pay roll quickly, promotions and house loan.

B.

Retention Strategy

Nurses were asked what single thing would help to retain them in the district. The majority (94%) indicated improving working conditions (increasing salary -55% , increasing allowances -15%, improving accommodation, toilets, water, electricity, communication, leadership skills and transport- 24%).

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4.2.6

Summary of Major Findings From Quantitative Data

Major findings from quantitative data were: Nurses chose nursing as a career because they wanted to help the sick (73%). Nurses joined government because of job security (39%) good career path (25%). Nurses were dissatisfied working in Machinga because of bad attitudes of DHMT and health workers (49%), increased workload (22%) and lack of resources and equipment (12%). Half of the nurses (53%) showed interest to continue working in government health facilities Almost all nurses (94%) indicated that improving working conditions (increasing salary and a locum scheme) would help to retain nurses in the district.

4.3

Results From Focus Group Discussion 4.3.1 Factors That Made Nurses Stay In Machinga District.

During focus group discussions, nurses were asked on what made them stay in Machinga District. In two FGDs conducted for nurses in government health facilities, the nurses reported that nursing as a profession and social relationships made them stay in the district.

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A.

Social Relationship

Nurses from the district hospital and health centres expressed that they stay in the district because of social relationship. Some of the respondents reported that:

P: there is good interrelationship, leadership and support during bereavement and there is not much segregation. District nurse: (appendix 1A) P: Am pending retirement so I dont want to go away as am used to the community. Health Centre nurse. (Appendix 1A)

B.

Nursing as a Profession

Nursing as a profession is about helping the sick and the nurses indicated that they stay in Machinga because they love the profession: P: I stay here because of the love for the profession. District nurse: (appendix 1A) P: the love for the profession and the hope that things would one day improve. Health Centre nurse. (Appendix 1A)

C.

Physical Environment

Nurses from district hospital also stated that the physical environment is conducive for someone to stay in the district.

26

P: the environment is clean and during morning report, we discuss patients conditions that is why I refuse going to health centres, as there is no continued education. District nurse: (appendix 1A)

D.

Workshops

Others stayed at the district hospital because of workshops. P: there are a lot of workshops that act as income generating activity. District nurse: (appendix 1A)

E.

Incentives

Nurses in Machinga district stay in CHAM health facilities because of incentives and decreased workload. It was learnt that CHAM institutions offer more incentives that attract nurses in the district. P: in CHAM, nurses are employed at TO grade-which is non-established in government service; free water and electricity, additional package on top of salary, low rental fee, easy acquisition of loans, we are paid more for locums (840.00/day) and there is no night duty for locum, the houses are well maintained and a bit bigger. (Appendix 1A)

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4.3.2 A.

What Makes Nurses Leave Government in Machinga District Lack of Incentives

Nurses leave government in Machinga because of lack of incentives. It was noted that the DHMT was not providing incentives to its staff as most of them pointed out that:

P: there are no privileges as compared to other districts in Malawi e.g. hot meals, allowances for locum allocations-clinicians and registered nurses are benefiting more, in other districts, transport pick them during working hours), poor housing conditions or no housing at all also there is no renovations to houses despite deducting housing allowances and accommodation is not considering grade as support staff are given priority for accommodation in most cases. District nurse: (appendix 1B)

P: in health centres nurses do not have privileges as compared to nurses at the district hospital e.g. hot meals and locum allowances. Health Centre nurse. (Appendix 1B)

B.

Health Centre Allocation

The health centre postings frustrated nurses in the district as they did not want to go to health centres. When they were posted to health centres, they asked for transfers to other districts or resigned from the service as they did not want to be posted to health centres. So the DHMT had a policy whereby nurses were rotating at health centres for three months. Still this also was not a welcome policy as one participant expressed that:

28

P: health centre allocation frustrate us as children in health centres do not go to good schools, personal problems are overlooked when posting us and in health centres we do work that we did some time back. District nurse: (appendix 1B)

C.

Poor Leadership Skills

Poor leadership skills of the management made nurses to leave the district hospital in Machinga. It was noted that:

P: there is poor approach by the management during health centre allocations, no staff appraisal, no coordination between nurses and clinicians and feed-back takes long. District nurse: (appendix 1B)

D.

Poor Transport And Communication Network

Health centre nurses added that poor transport and communication network made nurses refuse health centre posting. When you are posted to health centres, you are cut from communication and there is no transport due to poor road network, said one respondent.

29

4.3.3

Factors That Can Increase Nurses Motivation, Retention And Job Satisfaction In The District

Nurses in health centres indicated that providing incentives and improving communication and transport could motivate them to stay in health centres. Nurses at district hospital indicated that providing incentives and improving on leadership skills could motivate them to stay in the district. The majority (95%) clapped hands when one said the MOH should increase salary to K60, 000 per month as net pay for the lowest Enrolled Nurse/Midwife and send them to school.

4.3.4

Summary Of Major Findings From Focus Group Discussion

Major findings from focus group discussion were: 1. Nurses stayed in Machinga district because of social relationship, physical environment, professionalism and workshops while nurses in CHAM stayed because of incentives and decreased workload. 2. Nurses left government health facilities in Machinga because of lack of incentives, health centre allocation, poor leadership and poor transport and communication network. 3. Nurses could be motivated by increased salary, incentives and improved leadership skills, communication and transport

30

4.3.5

Summary of Major Findings From The Survey and FGD

Major findings of the study were: Bad attitudes of Health Management Team and health workers, and poor working conditions (workload, lack of resources and incentives, health centre allocation, poor transport and communication network) dissatisfied nurses in Machinga.. Nurses were satisfied working in Machinga District because of social reasons (good interpersonal relationship and support during bereavement), clean physical environment, professionalism and workshops. Factors that could help to retain nurses in the district included increasing salary to K60, 000 per month, providing incentives and resources at all levels, improving working conditions (education, housing, toilets, water, electricity or buying enough paraffin, communication and transport, rotations) in health centres and improving on leadership skills at district hospital.

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CHAPTER 5.0

DISCUSSION

5.1

Introduction

This chapter presents a discussion of key issues arising from the study. The following will be discussed: factors contributing to job satisfaction and dissatisfaction to nurses, nurses perceptions towards nursing as a career, factors that can be utilized to increase nurse retention in the District, limitations and recommendations of the study.

5.2

Job Satisfaction

Nurses were satisfied by working in Machinga District because of social relationships (good interpersonal relationship and support during bereavement), clean physical environment, love for the profession and workshops. Castle [4] indicated that characteristics of the work environment (leadership, stress, advancement opportunities and participation) are important in relation to nurses job satisfaction. Job satisfaction has both external and internal contextual factors. External factors that affect job satisfaction comprise additional rewards such as release and support from work due to family matters as bereavement. Extrinsic work values such as job security and workshops are also considered to be important in job satisfaction. The internal contextual factors are less substantial but inherent to work. These could be factors that are controlled by external forces and directly affecting internal employee satisfaction, such as workload, working environment and support from administration. Internal contextual factors are controlled by the professional himself/herself and have influence

32

on employee career satisfaction. So the DHMT and all staff should continue supporting the nurses and build on this as the strength in retaining nurses in the district.

However, there was contradicting information. In quantitative study, nurses indicated that they were dissatisfied working in Machinga District because of bad attitudes of DHMT and health workers while in focus group discussion, it was stated that nurses were satisfied working in Machinga District because of social reasons (good interpersonal relationship and support during bereavement). This showed that nurses were free to express themselves in self administered questionnaire than in focus group discussion where some members just echoed what a colleague said.

5.3

Job Dissatisfaction

The results indicated that bad attitudes of Health Management Team and poor working conditions (workload and lack of resources) dissatisfied nurses to work at Machinga district hospital. While in health centres, nurses were dissatisfied because of poor working conditions (no rotation, no communication, lack of transport, workload and lack of resources). These findings mirror those of Mackintosh, (2003) and these contribute to poor nurse retention in the district. Initiatives such as team work, increasing locum, salary increment to K60, 000 per month as net pay for the lowest Enrolled Nurse/Midwife, availability of resources and equipment may motivate or satisfy nurses at Machinga District Hospital. In addition, improving facilities and

working conditions (housing, toilets, water, electricity or buying enough paraffin), increasing locum, improving communication and transport could motivate or satisfy

33

nurses in Health Centres of Machinga District. From these findings, factors that dissatisfied nurses at a district hospital were different from those of nurses at health centres. Health centre staff expressed concerns over poor working conditions in terms of lack of houses, toilets, water, electricity and paraffin in addition to workload and lack of resources as expressed by district nurses. Therefore, these findings could be important when focusing on future policy initiatives on nurse retention in the district that need to be looked at or dealt with separately. It was also revealed that dissatisfaction from poor working conditions was a common factor among nurses in health centres and the district hospital. The MOH and DHMT need to look at these as a priority in the district as quality of working environment for nurses is extremely important in job satisfaction. Therefore, the DHMT and MOH need to improve on working conditions by ordering more resources. The DHMT should make sure that there is water, electricity or paraffin, toilets and communication in all health centres. The MOH needs to improve on working conditions by building houses and reviewing the locum system. And lastly, the nurses must take care of these resources.

In FGD, participants complained that there were no privileges for nurses in Machinga District as compared to nurses in other districts who were getting: hot meals, transport picking them to and from work during working days, allowances for locum were flat rates and they were being given a priority for accommodation as compared to support staff. Since some hospitals provided additional allowances, they stood a better chance to attract and retain nurses. It is indicated that disparities among facilities contribute to internal migration [22]. The DHMT needs to provide some of these incentives to nurses like hot meals and tea to night staff as they start night duty at 5.00 pm to 8.00 am.

34

Priority for accommodation should be to nurses and clinicians. Even to districts where they provide more allowances and hot meals, it is not known how effective the allowances are in motivating and retaining nurses in the districts. These monetary incentives are difficult to sustain. They are effective for a short time. If they are received for a long time, they may be viewed as an entitlement and may no longer have the intended impact. On the other hand, withdrawing the monetary incentives could present problems since they are used to. The long term solutions to satisfy and retain nurses must address other root causes like housing, communication, transport and attitudes.

Nurses from health centres also complained that they did not get what nurses working at a district hospital were receiving, for example: hot meals, locum and off duties. The DHMT needs to treat all nurses in the district the same. If nurses at the district hospital were being given hot meals and locum allowance, the health centre staff also needed to benefit as they are also understaffed and they work without off duties. But nurses at the district hospital still complained that what they were getting was not enough as compared to other staff in other districts in Malawi. The MOH needs to standardize these locums in all districts and health centres to prevent internal migration. The government move towards giving incentives and improving working conditions to remotest areas would be a very welcome idea and needed to be implemented and controlled centrally in order to attract and retain nurses in all districts and rural areas in Malawi.

35

The results showed that 26% of the nurses had intentions of leaving the government health services as they wanted to resign and join other non-governmental organisations or to retire and rest at home. Shields and Ward [7] expressed that those individuals, who reported dissatisfaction with their job, overall were 65% more likely to hold an intention to quit than those reporting to be satisfied. From these findings, shortage of nurses was likely to continue to exist in Machinga due to low salaries, personnel attitudes, workload and lack of resources. Retention strategies needed to focus on improving pay, interpersonal relationship, infrastructure and resources. These were to be implemented by the individual health workers, management team, and the Ministry of Health and its partners. These needs however, were already in pipe line with SWAP programme by the MOH whose main goal is to improve the health and well-being of all Malawians through improved access to quality and effective health services [17]. The MOH and its partners needed to improve the infrastructure, increase trained and skilled health personnel, have adequate supplies and effective policies to retain health workers. Inorder to develop effective policies for retention of health workers, the health workers should be involved for their contribution. For example, the nurses in Machinga indicated that for them to be satisfied, the salary should be not less than K60, 000 per month as net pay for an Enrolled Nurse/Midwife, which is the lowest cadre for nursing. This gives a 329% salary increase per month as the present net pay salary for an EN/M is about K14, 000 per month. This would be over-increase expectation and might not be feasible by the MOH. The MOH should rather copy from CHAM on their retention strategies such as providing incentives like; promoting EN/M and NMT to TO grade, free water and electricity, low rental fee, easy acquisition of loans, increasing locum, maintaining and building houses. These may attract nurses. Reduced workload may lead

36

to nurses satisfaction in their work and to be retained in government health facilities. Therefore when making policies, there was need to involve nurses at all levels for their input.

On the other hand, it was found out that the district still had a core group of dedicated nurses who wanted to help the sick and almost half of the nurses (53%) showed interest to remain or work in government as they indicated that they were hoping to go to school for upgrading. If these nurses do not go to school, they will eventually be frustrated and show signs of dissatisfaction. Shields and Ward [7] revealed that job dissatisfaction resulting from lack of promotion and training opportunities had a stronger impact than workload and pay. MOH policies should therefore focus heavily on developing training opportunities and career path for the nurses. Better retention strategies would in turn lead to reduced workload and reduced workload would lead to job satisfaction. The results have also shown that job satisfaction is influenced by both financial and nonfinancial benefits and therefore both benefits should be taken into consideration when developing motivation strategies.

5.4

Perceptions on Nursing as a Career

Choosing nursing again as a career and recommending nursing as a career to a relative or children was an important factor that showed if nurses were satisfied with their work or not. Results indicated that 73% chose nursing as a first choice career and after working as nurses, most nurses (87%) would still have chosen nursing as their career. This showed that other nurses had developed interest in nursing as a career in the course

37

of working. Also 72% of the nurses indicated that they would recommend their children to choose nursing as a career because of job security. Comparing the 87% that would still have chosen nursing and the 72% that would have recommended their children to choose nursing as a career, there is a drop in yes responses by 15% because of infections, increased workload and low salary. This meant that there was lack of job satisfaction or interest in nursing as a career. This also showed that nursing was a less motivating career to advocate to the young ones and if advocated, it would be for job security in government.

38

CHAPTER 6.0
6.1 Conclusion

CONCLUSION AND RECOMMENDATIONS

The study has revealed that Job satisfaction is influenced by both financial and nonfinancial benefits and should be taken into consideration when developing motivation strategies such as improving on communication and transport and improving on leadership skills. Therefore, the DHMT should look into these factors separately in order to attract and retain nurses in the district and at different levels.

6.2

Recommendations

The following were suggestions expressed by the researcher.

6.2.1

Recommendations for Research

More research has to be done on: How job satisfaction affects job performance How 52% top up salary would influence job satisfaction, performance and intentions not to quit. The study should be replicated in other districts in a large sample so that the results should be generalized to all nurses in Malawi.

6.2.2

Recommendations for Nursing and Midwifery Practice

Nurses need to work as a team and to rotate in health centres as people in the rural community need their care.

Managers need to intensify on professionalism in the service.

39

6.2.3

Recommendations for DHMT

The DHMT should: Review the locum system at a district level. Provide non-monetary incentives providing night meals, houses to nurses and conducting supervision Order more equipment and resources Improve on transport and communication

6.2.4

Recommendations for MOH

The MOH should: Review the locum system. Provide additional incentives Provide training and promotions Order more equipment and resources Build big houses in the districts and health centres Improve on transport and communication in terms of advocating for road networks and ambulances

6.2.5

Recommendations for Professional Development

Nurses should go to school for upgrading and professional development

40

6.2.6

Recommendations for Education

Training institutions should train more nurses to increase human resource hence reducing workload.

Teach professionalism and health centre management in training institutions so that nurses do not refuse health centre postings and that they are prepared to manage health centres.

41

REFERENCES
1. Hasselhorn HM, Tackenberg P, Muller BH. Working conditions and intent to leave the profession among nursing staff in Europe. ISSN: 1403-790X. Report No 7: 2003 [Accessed 23 Nov 2006]. Available at www.arbetslivsinstitutet.se. 2. Pearson CA. An assessment of extrinsic feedback on participation, role perceptions, motivation and job satisfaction in a self managed system for monitoring group achievement. Human relations 1991; 44 (5); 517-537 3. Syptak J, Marsland DW, Ulmer D. Job Satisfaction: Putting Theory into Practice. Family Practice Management, October 1999 [Revised December 2000. Accessed 23 Nov 2006]. Available from http://www.aafp.org/fpm/991000fm/26.html. 4. Castle N, Degenholtz H, Rosen J. (2006). Determinants of staff job satisfaction of care givers in two nursing homes in Pennsylvania. BMC Health Services Research [on line] May 2006, 6:60 [Accessed 20 Nov 2006]. Available from http://www.biomedcentral.com/1472-6963/6/60 5. Mackintosh LS. A Study identifying factors affecting retention of Midwives in Malawi. Liverpool School of Tropical Medicine; 2003.

6. Gagnon S, Ritchie J, Lynch A, Drouin S, Cass V, Rinfret N, Rouleau C, Valois M. Job Satisfaction and Retention of Nursing Staff: The Impact of Nurse Management Leadership. Canadian Health Services Research Foundation: 2006. [Accessed 20 Nov 2006]. Available from www.chsrf.ca/final_research/ogc/gagnon.

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7. Shields MA, Ward ME. Improving nurse retention in the British National Health Service: The impact of job satisfaction on intentions to quit. CEPR Discussion Papers: 2003 No. 2806. [Revised 2001; Accessed 20 Nov 2006]. from URL:ftp://repec.iza.org/RePEc/DiscussionPaper/dp//118. 8. Backman A. Job Satisfaction, Retention, Recruitment and Skill Mix for a Sustainable Health Care System. A Report to the Deputy Minister of Health for Saskatchewan. Elsevier 2000; 20 (5). 9. Clark A, Georgellis Y, Sanfey P. Job Satisfaction, Wages and Quit: Evidence from German. Research in Labor Economics 1998; 17:95-121. 10. Maslow A. A Theory of Human Motivation. ISSN 1492-3713. Psychological Review 2000; 50:370-96. 11. Irvine DM, Evans MG. Job satisfaction and turnover among nurses. Integrating research findings across studies. Nursing research 1995; 44:246-253. 12. Dielema M, Cuong PV, Anh LV, Martin T. Identifying factors for job motivation of rural health workers in North Viet Nam. Human Resources for Health 2003; 1: 10. 13. Dowell AC, Hamilton S, McLeod DK. Job satisfaction, psychological, morbidity and job stress among New Zealand general practitioners. NZ Med. Journal 2000, 6 (113):269-72. 14. Dovlo D. The Brain Drain and Retention of Health Professionals in Africa. A case study prepared for a regional training conference on improving tertiary education in Sub Saharan Africa: Things That Work: 2003; 23-25. 15. Keetle JL. Factors Affecting Job Satisfaction in Registered Nurses. University of North Carolina, Charlotte, NC; 2005. Available

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16. Government of Malawi and Japan International Cooperation Agency. Malawi Health Facility Survey 2002 Report. Lilongwe, Malawi; Ministry of Health and Population; 2002. 17. Malawi Health SWAp Donor Group GTZ / UNDP. Human Resources / Capacity Development within the Health Sector. Needs Assessment Study Report; 2007. 18. Department for International Department (DFID). 2005 Autumn Performance Report. Malawi emergency human resource programme- measuring progress; 2005. [Accessed 12 Dec 2006]. Available from

http://www.official_documents.gov.uk/documents/cm67/6706/6706. 19. Harries AD, Hargreaves NJ, Gausi F, Kwanjana JH, Salaniponi FM. High death rates in health care workers and teachers in Malawi. Transactions of the Royal Society of Tropical Medicine and Hygiene 2002; 96:34-7. 20. Nurses and Midwives Council of Malawi. Nurses validated abroad; 2006. 21. Muula, AS, Maseko FC. How are health professionals earning their living in Malawi? BMC. Health Services Research 2006; 6: 97. 22. Caffrey M, Frelick G. Attracting and retaining nurse tutors in Malawi. Health Workforce. Innovative Approaches and Promising Practices. Intrahealth International. Study series; 2006. 23. Department for International Department (DFID). Project Memorandum. Malawi: Poverty Reduction Budget Support, 2004/05-2005/06. Financial Aid: 30 Million; December 2004. 24. Malawi Health SWAp Donor Group GTZ / UNDP. Government of Malawi, Health Service Commission, Tracing Employable Ex-Ministry Of Health Nursing And Clinical Employees Residing Inside And Outside Malawi; 2006.

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25. Dolea C, Zurn P, Stilwell. Nurse Retention and recruitment: developing a motivated workforce. WHO. Burdett Trust for Nursing; 2004. 26. Muula AS, Maseko FC. Survival and retention strategies for Malawian health professionals. EQUINET 2005:[32] 27. Machinga Health Management Information System. Annual Reports. Machinga Malawi, 2002-2006. Unpublished. 28. Malawi Demographic Health Survey. National Statistical Office. Zomba, Malawi; 2004. 29. Machinga District Nursing Officer. Annual Reports. Machinga, Malawi; 20022006. Unpublished.

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APPENDIX 1: QUOTES FROM FOCUS GROUP DISCUSSIONS

Appendix 1a: What Makes Nurses Stay In Machinga District
VARIABLE what makes nurses stay in Machinga District NURSES IN GOVERNMENT RESPONSES FROM NURSES IN DISTRICT HOSPITAL Social reasons, there is good interrelationship and support during bereavement and there is not much segregation; I feel good working with colleagues; I need to be where my husband is; education of the children; there is good coordination and support from management; Physical environment there is fresh chambo, the work place is near home, clean environment; during morning report, we discuss patients conditions -thus why I refuse going to health centres, as there is no continued education; Professionalism the love for the profession Workshops; there are a lot of workshops that act as income generating activity. NURSES IN CHAM Incentives like TO grade-which is non-established for nurses in government service; free water and electricity, additional package on top of salary, low rental fee, easy acquisition of loans, we are paid more for locums ( K840.00/day) and there is no night duty for locum , the houses are well maintained and a bit bigger decreased workload- a good and manageable nurse-patient ratio;

RESPONSES FROM NURSES IN HEALTH CENTRES Professionalism the love for the profession; the hope that things would one day improve; Social reasons, pending retirement so I dont want to go away;

46

APPENDIX 1B: Why nurses in government service leave Machinga District compared to why nurses in CHAM stay in Machinga District
VARIABLE What makes nurses leave government and stay in CHAM facilities in Machinga District LEAVE GOVERNMENT RESPONSES FROM NURSES IN THE DISTRICT HOSPITAL Incentives no privileges as compared to other districts in Malawi e.g. hot meals, allowances for locum allocationsclinicians and registered nurses benefiting more, transport pick them during working hour); no access to loans, poor housing conditions or no housing at all (no renovations to houses despite nurses being deducted housing allowances equally ;accommodation not considering grade (support staff given priority for accommodation in most cases), Health centre allocation frustration as a result of health centre allocation as children in health centres do not go to good school, personal problems are overlooked, in health centres we do work that we did some time back; STAY INCHAM

Incentives like free water and electricity, additional package on top of salary, low rental fee, easy acquisition of loans, they were paid more for locums ( K840.00/day) and there is was no night duty TO grade-which was non-established for nurses in government service; Accommodation there is good accommodation and the houses are well maintained and a bit bigger decreased workload-due to a good and manageable nurse-patient ratio

Poor leadership skills poor approach by the management, no staff appraisal, no coordination between nurses and clinicians and feed-back take long.

RESPONSES FROM NURSES IN HEALTH CENTRES Incentives no privileges as compared to other districts in Malawi e.g. hot meals, allowances for locum allocations, poor housing conditions or no housing at all as there is no renovations to houses despite deducting housing allowances. Lack of supervision lack of proper supervision, and feed-back take long; Poor transport and communication network when you are posted to health centres, you are cut from communication and there is no transport due to poor road network.

47

APPENDIX 1C: FACTORS TO BE UTILISED TO INCREASE JOB SATISFACTION

Showing Relationship Among Responses Within Government Health Facilities Levels
Variable What needs to be done to increase nurses motivation and job satisfaction in the district. In health Centres In centives improve working conditions by increasing locum allowance, improving on housing, toilets, water, electricity or give health centres enough paraffin Improve communication and transport At district level In centives improve nurses welfare (access to loans, hot meals, and good accommodation, Introduce flat rate for locum, revisit remuneration package, equality and equity in workshops, conduct in-service training; recognize hard-working nurses. improve on leadership skills (approach, supervision, appraisal, , change programme coordinators, improve communication, and conduct regular meetings with clinicians At ministry of Health level introduce nice package for nurses. send nurses for further studies (Intake for upgrading should combine both practice (performance) and interview50-50;

48

APPENDIX 2 -SELF-ADMINISTRATED QUESTIONNAIRE

Date: .

The following information is being collected to solicit factors that influence you to be satisfied with your job as a nurse. Please respond to the questions to the best of your ability. Remember, all the information will be kept completely confidential, therefore, do not write down your name. Consent: Would you accept to answer the following questions? (Tick where appropriate) a) Yes b) No

INSTRUCTIONS [1] Answer every question with a tick or a short response where appropriate in the space provided. [11] If there are more answers to some questions, indicate with numbers in order of priority starting with 1, 2, 3 etc. 1. What is your sex? a) b) female male

2. What is your age in years? 3. For how many years have you been a nurse? .. 4. Who is your present employer? a) b) c) d) e) Government CHAM BLM District Assembly Privately employed

5. Have you ever been employed in government service? (Only for those not in Governments) a) b) Yes No

49

(i) If yes, Why did you leave? .. (ii) If no, Why not joining Government?.. (Go to Question 7)

6. Why did you join government service? (If more answers, indicate with numbers in order of priority). a) Job security b) Good career path (school) c) Only job which was available d) Good collaboration e) Others (specify) 7. What is your marital status? a) Single b) Cohabiting c) Married d) Divorced e) Separated f) Widow 8. What is your cadre? a) Registered Nurse b) Registered Nurse/Midwife c) Enrolled Nurse d) Nurse Technician e) Nurse Midwife Technician f) Other specify.

50

9. Was nursing your first choice career? a) Yes (then go to Q10) b) No (go to Q11) 10. What was the main reason for choosing nursing as a first choice career? a) To help sick people b) Interesting career c) Interest in science subject d) Job availability e) Need for money f) Was forced by parents g) Others specify. 11. What was the main reason for not choosing nursing as a first choice career? a) b) c) d) e) f) g) Dislike dying people Low salary Dislike sick people Hours that nurses work Fear for getting diseases Nurses are not recognized by Government Others specify

12. After working as a nurse, would you still have chosen nursing as a career today? a) Yes b) No Give reasons for your answer .. 13. Would you recommend your child, relative or best friend to choose nursing today? a) Yes b) No 51

Give reasons for your answer 14. What makes you to be satisfied working in Machinga District? (If more answers, indicate with numbers in order of priority) a) good interpersonal relationship b) good leadership c) clean surrounding d) recognition on achievements e) a lot of workshops f) there is autonomy ( independence) g) The hospital is new and modern h) Others (specify) 15. What makes you dissatisfied working in Machinga District? (If more answers, indicate with numbers in order of priority). a) workload b) lack of equipment and resources c) bad attitudes of health workers d) bad attitudes of health management team e) Patients are very demanding f) Others (specify).. 16. For you to be motivated, what would you recommend the:(If more answers, indicate with numbers in order of priority). 16.1 Health workers to do? a) work as a team b) help each other in terms of problems c) Do more relief work at health centres d) Rotate in the health centres e) Others (specify).. 52

16.2 Health Management Team to do for you? a) b) c) d) Increase part time allowance Order more equipment and resources Discipline health workers with bad attitudes Others (specify)..

16.3 The Ministry of Health to do for you? a) b) c) d) e) f) Increase salary Employ more nurses Introduce risk allowance Train more nurses Introduce exchange visits with other nurses outside Malawi Others (specify)

17. 1. What is your future plan on nursing as a career? a) b) c) d) e) f) g) h) 17. 2 Resign and join other Non-Governmental Organizations Resign and join Government Resign and go to work abroad Continue serving the government as it is interesting Retire and rest at home Retire and work month to month Continue serving as I have no where to go and work Others (specify)

Give reasons for your answer in A above....

18.

What single thing would help to retain you in the district?

53

APPENDIX 3: QUESTION GUIDE FOR FOCUS GROUP DISCUSSION

Seating (around) Introductions Brief introduction of the survey Focus Group Discussion (No right or wrong answers. Disagree is okay) Confidentiality Tape record (because cant remember by heart) Take notes (in case tape breaks down)

Guides: Why do nurses leave the job in Machinga? What makes nurses stay in Machinga? What makes nurses stay in CHAM and private clinics as compared to public services in Machinga? How do you make ends meet? (Other financial gains) When nurses leave the job in Machinga, where do they go? What can be done to retain nurses in Machinga District?

Summarise points raised Thank participants

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APPENDIX 4 - LETTERS OF PERMISSION

University of Malawi College of Medicine Private Bag 1 BLANTYRE 20th December, 2006. The DHO Balaka District Hospital, P.O. Box BALAKA

Dear Sir, REQUEST TO USE BALAKA DISTRICT AS A PILOT RESEARCH SITE I am a second year student at College of Medicine pursuing a Master of Public Health. I intend to conduct a research project as part of the course requirement. The title of the study is Improving nurse retention: Factors influencing job satisfaction of all cadres of nurses in Machinga District.. I would like to request your permission to utilize 4 nurses in your district to pre-test the questionnaire to see if it can be answered. The questionnaire will later be used for the study in Machinga District. I intend to do this in Mid January, 2007. A self administered questionnaire and 1 focus group discussion will be used to collect data. There are no risks involved in this pilot study.

Your consideration will be greatly appreciated.

Yours faithfully

Mrs. J. T. Mtengezo 55

University of Malawi College of Medicine Private Bag 1 BLANTYRE 20th December, 2006. The DHO Machinga District Hospital, P.O. Box 44 LIWONDE

Dear Sir, REQUEST TO USE MACHINGA DISTRICT AS A RESEARCH SITE I am a second year student at College of Medicine pursuing a Master of Public Health. I intend to conduct a research project as part of the course requirement. The title of the study is Improving nurse retention: Factors influencing job satisfaction of all cadres of nurses in Machinga District. I would like to request your permission to utilize all the nurses in your district both in CHAM, private and Government health facilities to be research subjects for the study from January, 2007. A self administered questionnaire and focus group discussions will be used to collect data. There are no risks involved in the study and the results would help to design strategies to motivate, satisfy and retain nurses in the district and come up with revised policy and recommendations for nurse retention in the District. Your consideration will be greatly appreciated.

Yours faithfully

Mrs. J. T. Mtengezo 56

College of Medicine P.O. Box 1 BLANTYRE To: All nurses in Machinga District, P.O. B ox 44 LIWONDE

Dear Sir/Madam INFORMED CONSENT I am a second year student at College of Medicine pursuing a Master of Public Health. I intend to conduct a research project as part of the course requirement. The title of the study is Improving nurse retention: Factors influencing job satisfaction of all cadres of nurses in Machinga District. You will all be involved in the study to answer some questions on a questionnaire and 12 nurses from Government facilities and 6 nurses from CHAM and private facilities will be involved in focus group discussions. It will be done in January, 2007. No risks are associated with the study and the results would help to design strategies to motivate, satisfy and retain nurses in health facilities and come up with revised policy and recommendations for nurse retention in the District. For confidentiality, names will not be written down and as soon as the questionnaires are completed the research assistants will collect them. Upon completion of the study, the questionnaire will be destroyed but information will be used. You are free to refuse or withdraw your consent and no punishment measures will be exercised. Thank you in advance. Yours faithfully

Mrs. J. T. Mtengezo 57