University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEATH SCIENCES UNIVERSITY OF GHANA ASSESSMENT OF FACTORS INFLUENCING JOB SATISFACTION AMONG NURSES AT THE GREATER ACCRA REGIONAL HOSPITAL BY CONSTANCE ACQUAH (10331790) THIS DISERTATION IS SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH, COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Constance Acquah, hereby declare that this is the result of my own hard work and that no previous submission for master‟s degree has been done here or elsewhere. Additionally, works of others, which served as references have been duly acknowledged. …………………………….. ………………………………. Constance Acquah Dr. Augustine Adomah-Afari (Student) (Supervisor) …………………………..…. ………………………………… Date Date i University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is first and foremost dedicated to God Almighty for His great protection, wisdom and knowledge to go through this academic exercise. I also dedicate it to my family for their prayers and encouragement. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My profound appreciation goes to the God Almighty for the strength and opportunity given to me to be part of this accomplishment. I also wish to express my gratitude to my supervisor, Dr. Augustine Adomah-Afari, School of Public Health, College of Health Sciences, University of Ghana - Legon for his valuable guidelines, knowledge and recommendations through every phase of my project. Thanks also go to all the lecturers at the School of Public Health, College of Health Sciences, University of Ghana - Legon for their dedicated efforts in preparing us for the academic work. Many thanks go to the Medical Director, Administrators, Head of Nursing and all the entire nursing staff at the Greater Accra Regional Hospital for their support by giving me the opportunity to conduct a study at the facility and also made time to respond to the questionnaires. I also wish to express my sincere thanks to my research assistant Mr. John Abban, at the Greater Accra Regional Hospital for his dedicated support and contribution. I owe a very special thanks to my family for their great support and encouragement, especially my husband, Mr. Abraham. K. Amoah, my mother, Madam Anna Mensah, and my children Albertha, Samuel and Ebenezer. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Job satisfaction is one of the most important components that can impact on productivity and performance in an organization. Nursing job satisfaction is critical since it enhances commitment, retention and turn over which subsequently, influence the quality of care and patient satisfaction. Objective: This study investigated factors associated with job satisfaction among nurses at the Greater Accra Regional Hospital, Ghana. Methods: Descriptive cross-sectional study with quantitative method was applied. Structured questionnaires were used with 233 nurses as sample size. Data collection was carried out using simple random sampling technique. Statistical analysis of data was done by using Stata V15. Descriptive analysis was carried out and linear regression model was used to establish association and test strength of associations respectively. Results: Overall, there was low job satisfaction 2.9 (SD=0.6) among the nurses at the Greater Accra Regional Hospital.There was low satisfaction with regards to the policies concerning nurses 2.9 (SD=0.7), promotion 2.8 (SD=0.9) and motivation 2.7 (SD=0.9) with remuneration 2.3 (SD=0.8) recording the least. However, there was high satisfaction with teamwork 3.3 (SD=0.7) and supervision 3.6 (0.5). Age, marital status, years of experience, years of practice at Greater Accra Regional Hospital, position/rank, and the nature of the ward heaviness were significantly (p < 0.001) related to job satisfaction among the nurses. Conclusion: The study revealed that there was low job satisfaction among nurses at the Greater Accra Regional Hospital. While the nurses were not satisfied with most of the organizational factors, there was high satisfaction with the level of supervision and teamwork. With the nurses‟ factors, it was concluded that age, marital status, years of experience, years of practice, position/rank, and the nature of the ward were significantly related to job satisfaction among the nurses. Based on the conclusions, recommendations made were to relook at the policies regarding nurses at the hospital, including promotion, motivation and remuneration. Nurses should be involved in decision-making processes. Further studies have been recommended toward determining the quality of care at the hospital. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ........................................................................................................................ i DEDICATION ........................................................................................................................... ii ACKNOWLEDGEMENT ....................................................................................................... iii ABSTRACT .............................................................................................................................. iv LIST OF FIGURES ................................................................................................................... x DEFINITION OF TERMS ...................................................................................................... xii CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.0 Background to the study ................................................................................................... 1 1.1. Problem Statement ........................................................................................................ 2 1.2. Justification of the Study ................................................................................................. 4 1.3 General Objective ............................................................................................................. 6 1.3.1. Specific Objectives ....................................................................................................... 6 Specifically the study addressed the following objectives: .................................................... 6 1.3.2. Research Questions ...................................................................................................... 6 1.4. Outline of the dissertation ............................................................................................... 7 CHAPTER TWO ....................................................................................................................... 8 LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK .......................................... 8 2.0. Introduction ..................................................................................................................... 8 2.1. Job Satisfaction ............................................................................................................... 8 2.2. Factors influencing Job Satisfaction ............................................................................... 9 2.3. Nurses‟ Factors /Socio-Demographic Characteristics of the Nurses ............................ 10 2.3.1. Age.......................................................................................................................... 10 2.3.2. Sex .......................................................................................................................... 12 2.3.3. Marital Status .......................................................................................................... 13 2.3.4. Position and Rank ................................................................................................... 14 2.3.5. Level of education .................................................................................................. 15 2.4. Institutional Factors influencing Job Satisfaction ......................................................... 16 v University of Ghana http://ugspace.ug.edu.gh 2.4.1. Policies.................................................................................................................... 16 2.4.2. Supervision ............................................................................................................. 17 2.4.3. Teamwork ............................................................................................................... 18 2.4.4. Promotion ............................................................................................................... 19 2.4.5. Motivation .............................................................................................................. 20 2.4.6. Remuneration.......................................................................................................... 21 2.5. Conceptual Framework ................................................................................................. 23 2.6. Chapter Summary .......................................................................................................... 24 CHAPTER THREE ................................................................................................................. 25 METHODS .............................................................................................................................. 25 3.0. Introduction ................................................................................................................... 25 3.1. Study Design ................................................................................................................. 25 3.2. Study Location/Area ..................................................................................................... 26 3.3. Study Population ........................................................................................................... 27 3.3.1. Inclusion Criteria .................................................................................................... 27 3.3.2. Exclusion Criteria ................................................................................................... 28 3.4. Study Variables ............................................................................................................. 28 3.4.1. Dependent variable ................................................................................................. 28 3.4.2 Independent variable ................................................................................................ 28 3.5. Sampling Method .......................................................................................................... 30 3.5.1. Sample Size Determination .................................................................................... 31 3.6. Data Collection Technique: Questionnaire Design and Administration ....................... 32 3.7. Data Analysis ................................................................................................................ 32 3.8. Pretesting ....................................................................................................................... 34 3.9. Quality Assurance ......................................................................................................... 34 3.10. Validity and Reliability ............................................................................................... 34 3.11 Ethical Consideration ................................................................................................... 35 3.11.1. Participant Consent ............................................................................................... 35 3.11.2. Privacy and Confidentiality .................................................................................. 35 vi University of Ghana http://ugspace.ug.edu.gh 3.11.3. Risk and Benefits .................................................................................................. 36 3.11.4. Compensation ....................................................................................................... 36 3.11.5. Research Funding ................................................................................................. 36 3.11.6. Withdrawal from the study ................................................................................... 36 3.11.7. Data Storage ......................................................................................................... 36 3.12. Chapter summary ............................................................................................................ 37 CHAPTER FOUR .................................................................................................................... 38 RESULTS ................................................................................................................................ 38 4.0. Introduction ................................................................................................................... 38 4.1. Demographic characteristics of respondents ................................................................. 38 4.2. Assessment of job satisfaction ...................................................................................... 41 4.3. Assessment of institutional factors that influence job satisfaction ............................... 42 4.3.1. Assessment on policy ............................................................................................. 42 4.3.2. Assessment on supervision ..................................................................................... 43 4.3.3. Assessment on Team work ..................................................................................... 45 4.3.4 Assessment on promotion ........................................................................................ 45 4.3.5. Assessment on motivation ...................................................................................... 46 4.3.6. Assessment on remuneration .................................................................................. 47 4.4.1. Relationship between nurses‟ job satisfaction and socio-demographic characteristics .............................................................................................................................................. 48 4.4.5: Relationship between nurses‟ job satisfaction and facility factors ............................ 53 4.5.1. Chapter Summary ....................................................................................................... 54 CHAPTER FIVE ..................................................................................................................... 55 DISUCUSSION ....................................................................................................................... 55 5.0. Introduction ................................................................................................................... 55 5.1. Nurses‟ (socio-demographic characteristics) factors and job satisfaction .................... 55 5.2. Institutional factors influencing job satisfaction ........................................................... 56 5.2.1. Policy ...................................................................................................................... 56 5.2.2. Teamwork ............................................................................................................... 57 vii University of Ghana http://ugspace.ug.edu.gh 5.2.3. Supervision ............................................................................................................. 58 5.2.4. Promotion ............................................................................................................... 58 5.2.5. Motivation .............................................................................................................. 59 5.2.6. Remuneration.......................................................................................................... 59 5.3. Chapter summary .......................................................................................................... 60 CHAPTER SIX ........................................................................................................................ 61 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS............................................ 61 6.0. Introduction ................................................................................................................... 61 6.1. Summary of the study ................................................................................................... 61 6.2. Conclusions ................................................................................................................... 61 6.2.1. Nurses‟ (socio-demographic characteristics) factors influencing job satisfaction. 62 6.2.2. Institutional (facility related) factors influencing job satisfaction .......................... 62 6.3. Contributions to Knowledge ......................................................................................... 62 6.3.1. Contribution to policy and practice ........................................................................ 62 6. 3.2. Contributions to Theory......................................................................................... 63 6.3.3. Contribution to Management of healthcare institutions ......................................... 63 6.3.4. Contribution to methodology.................................................................................. 63 6.4. Recommendations ......................................................................................................... 64 6.5. Limitations to the study ................................................................................................. 64 6.6. Future research .............................................................................................................. 64 REFERENCES ........................................................................................................................ 66 APPENDICES ......................................................................................................................... 75 APPENDIX A: Participant Informed Consent form ........................................................ 75 APPENDIX B: Questionnaire .......................................................................................... 79 APPENDIX C: Participant Information Sheet ................................................................... 85 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Description of the study variables .......................................................................... 30 Table 4.1: Socio-demographic characteristics Cont‟d ............................................................ 40 Table 4.3.1: Assessment on policy ......................................................................................... 43 Table 4.3.2: Assessment on Supervision ................................................................................. 44 Table 4.3.4: Assessment on teamwork and promotion ............................................................ 46 Table 4.3.6: Institutional factors: Assessment on motivation and remuneration .................... 47 Table 4.4: Relationship between nurses‟ job satisfaction and socio-demographic characteristics ........................................................................................................................... 51 Table 4.4.1: Relationship between nurses‟ job satisfaction and socio-demographic characteristics Cont‟d............................................................................................................... 52 Table 4.5: Relationship between nurses‟ job satisfaction and facility factors ......................... 53 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 2.1: Conceptual Framework of factors influencing job satisfaction among the nurses. .................................................................................................................................................. 23 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS AMA Accra Metropolitan Assembly BNHS British National Health Service CD Compact Disc DDNS Deputy Director of Nursing Services GHS Ghana Health Service GHS ERC- Ghana Health Service Ethical Review Committee GARH Greater Accra Regional Hospital GSS Ghana Statistical Service MTTU Management of Trade Transport Union OKSM Osu-Klotey Sub-Metropolitan UK United Kingdom USA United State of America xi University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Nurse: A person who has been educated and trained to provide healthcare services to the sick. Patient: Anyone who needs physical, psychological, spiritual and social care from a healthcare provider. Care: the provision of essential service that is necessary for health of an individual or patient. Quality: Providing the best form of treatment that in acceptable and affordable to the patient. Job Satisfaction: how content a nurse is with his/her job and the sense of accomplishment gained from doing it or when a nurse is happy and feels good about his or her job. Socio-demographic characteristics: Intrinsic factors about the nurse that can influence his/her job satisfaction. Institutional factors: They are the structures within the institution that guides actions and operations of the institutions. xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background to the study A strong empirical evidence supports a causal relationship between job satisfaction, patient satisfaction and quality of care (Aron, 2015). It is argued that if civil servants feel more valued by society, they are more likely to have higher levels of public service motivation, which then contributes to higher levels of individual job satisfaction (Steel, Pierce, Berman, & Taylor, 2017). Job satisfaction is a critical factor in health care. In the US, between $450 and $550 billions of dollars are lost in a year due to job dissatisfaction, and one out of ten managers that die is as a result of dissatisfied employees (Gallup, 2013). Job satisfaction has been with us since creation, but there were no tools to measure until the emergence of social sciences in the 1930s (Saba, 2011). Human factor is the primary resource of health care system as it organizes and utilizes other resources for the production of intended output (Geleto, Baraki, Atomsa, & Dessie, 2015). Many researchers have defined job satisfaction in their own style due to its critical and complex nature, but there is one most cited definition of job satisfaction, which is the way people feel about their job and its various aspects (Spector, 1997). It has to do with the extent to which people like or dislike their job. Modern organizations seek to achieve customer satisfaction with all efforts. The hospital system is no exception to that course, but there is no way the approach will be attained without looking into the satisfaction of the employee (Bulgarella, 2005). The hospital system is a very complex system with multidisciplinary professionals collaborating to achieve a common goal, which is the patient satisfaction through quality care delivery. This mission is what the Greater Accra Regional Hospital seeks to achieve. 1 University of Ghana http://ugspace.ug.edu.gh Nursing profession forms the majority of health care professionals in the health care delivery arena and the profession has to be examined holistically in the quest to achieving quality care by assessing certain institutional factors that contribute to job satisfaction as well as the nurses‟ own socio-demographic characteristics (Aiken, 2002). This will ensure that effective strategies can be implemented to improve nurses‟ job satisfaction and the quality of patient care (Zarea, Negarandeh, Dehghan-Nayeri, & Rezaei-Adaryani, 2009). 1.1. Problem Statement Job satisfaction is currently, considered to be a measure that should be included in quality improvement programme in health care organizations (Antón, 2009). It is very important to determine factors associated with job satisfaction since this will ensure provision of quality care, as well as organizational efficiency and effectiveness (Gursoy, Chi, & Karadag, 2013). Additionally, job satisfaction ensures the sustainability of health care professionals in the health system. Dissatisfied health care providers are more likely to be inefficient and to provide poor quality care, and sometimes may react irrationally. All these will lead to unnecessary cost (Medgyesi & Zólyomi, 2016). The recent trend of strikes among health care workers, especially nurses, calls for an assessment of job satisfaction among nurses since there is evidence that medical doctors are more satisfied than nurses even though they all work in the hospital irrespective of their educational background (Iliopoulos & Priporas, 2011). Striking is known to be one of the ways deployed to demonstrate their dissatisfaction with their work (Manning, 2016). However, striking in health care provision is the worst thing to happen as it causes disastrous outcomes (Manning & Petrongolo, 2017). Thus, there is the need to recognize the determinants of job satisfaction among health care workers, especially the nurses who form 2 University of Ghana http://ugspace.ug.edu.gh majority of the hospital working population who are the health care cadre that need to avoid future occurrences of strikes (Naburi et al., 2017). Additionally, nursing is one of the most stressful jobs in the health sector and therefore, factor such as policies, supervision, promotion, motivation, remuneration and others that influence their satisfaction must receive attention since previous strikes of health workers were usually initiated by these nurses who usually reported about their poor institutional factors that hinder their efforts to provide quality care (Roelen, Koopmans, & Groothoff, 2008). Studies have also shown that, socio-demographic characteristics such as age, sex, level of education, marital status, income level, position held at work, experience, among others, could lead to burnout, which subsequently could lead to job dissatisfaction (Garrosa, Moreno- Jiménez, Liang, & González, 2008). Earlier research also revealed that institutional factors and socio-demographic characteristics strongly affect job satisfaction among nurses (Hayes, Bonner, & Pryor, 2010). The Greater Accra Regional Hospital, seeks to regain its formal good name as a result of current frequent patients‟ reports in the media about their dissatisfaction with health care provision at the hospital, especially with the nurses (Anaba, 2016). Job satisfaction, has become an issue as a result of increased workload at the hospital due to expansion of the facility as well as acceptance of National Health Insurance Service clients (Laryea, 2017). Satisfaction of nurses is a key interest in the health system in this era to prevent brain drain of nurses, which almost rendered the nation‟s hospitals to total emptiness in the late 90‟s through early part of year 2000 due to nurses‟ dissatisfaction as results of bad policies, suppressions from their supervisors, lack of good promotion system and remuneration as well as lack of motivation compounded with the nurses‟ own factors (Tsikata, 2011). 3 University of Ghana http://ugspace.ug.edu.gh According to Liu et al. (2012), nurses characteristics such as age, sex, marital status, level of education, salary level, among others, affect their job satisfaction because these factors lead to schedule conflict, increased demand placed on the body, lack of childcare, increased opportunities for work related errors, increased mental stress, lack of career satisfaction and appreciation which will eventually affect the patients‟ care (Shonubi, Abdullah, Hashim & Hamid, 2016). Good Institutional factors and individual characteristics has been found to be the block foundation of job satisfaction and subsequently organizational commitment. Nurses‟ factors/socio-demographic characteristics of the nurse as well as institutional factors have direct impact on job satisfaction. Recent research have shown that, these factors affect the contextual performance of the nurse and must be investigated adequately to find remedy to avoid occurrences of future strikes and also to improve quality of care (Özden, Arslan, Ertuğrul, & Karakaya, 2017) 1.2. Justification of the Study The two-factor theory by Herzberg, also term as Herzberg‟s motivation-hygiene theory (1959), which projected certain institutional factors as attributes to job satisfaction still remain a fundamental reference to the subject (Frederick Herzberg, Mausner, & Snyderman, 1959). Another research by Duong (2013), also revealed that institutional factors such as supervision, leadership, administrative efficiency and others have significant effect on job satisfaction and since much exploration has not been done in that area, it will be justifiable to research deeper into that area, especially in Sub-Saharan context (such as Ghana) to find remedy to the situation (Duong, 2013). Job satisfaction has been a major issue in nursing, especially in Ghana, hence, frequent agitation for industrial strikes in the country (Appiah, 2015). This is all because of the fight for a better condition of service. Nursing in Ghana till date has no written down document on 4 University of Ghana http://ugspace.ug.edu.gh their condition of service to show. Some research have been done in the area of job satisfaction, especially in the USA, Canada, Sweden, the UK, and Australia, among others as compare to the sub-Saharan region (Aiken et al, 2012). However, few works done in this area in the local level indicated job dissatisfaction among these professionals. Perhaps scholars and stakeholders have not put much efforts to bring solution to the problem about the subject (Appiah, 2015). The most current research on job satisfaction among nurses at the then Ridge Hospital, focused on measuring the stress level between Pantang Hospital and Ridge Hospital in relation to job satisfaction, even revealed that there is higher level of stress at Ridge Hospital than Pantang Hospital (Assibi Rita, Atindanbila, Prudence Portia, & Abepuoring, 2013). Nevertheless, this study tries to observe or seeks to assess the determinants/factors of job satisfaction, and the influence of socio-demographic characteristics on job satisfaction among nurses at the Ridge Hospital currently, Greater Accra Regional Hospital. Similar work done by Ahmed et al. (2010), used the intrinsic and extrinsic factors to measure job satisfaction, but the approach seems different as the environment, economic factors and policies in his study differ from Ghana. This study area has a peculiar issue to address. The Greater Accra Regional Hospital is trying to redeem its former name/glory because of frequent reports in the media from patients about the hospital and their dissatisfaction of care from the nurses (Anaba, 2016). Since the nursing profession is the health care cadre that forms majority of the workforce in care delivery, it is important to assess their satisfaction and how it will impact on quality healthcare delivery. Employees will perform better when they feel singled out for special attention or feel that management is concerned about their welfare (Lambrou, Kontodimopoulos, & Niakas, 2010). 5 University of Ghana http://ugspace.ug.edu.gh Previous research done on job satisfaction was not in-depth and the context differs from the situation existing at the Greater Accra Regional Hospital. Therefore, this study seeks to fill the gap and also address issues related or peculiar to job satisfaction among the nurses at the Greater Accra Regional Hospital which may seems to be weak institutional factors that hider the nurses from giving out their best for clients satisfaction. This will contribute to the cause and course of trying to regain the confidence of the patients and the general public (Hayes, Bonner, & Pryor, 2010). 1.3 General Objective The general objective of this study was to assess factors influencing job satisfaction among nurses at the Greater Accra Regional Hospital. 1.3.1. Specific Objectives Specifically the study addressed the following objectives: 1. To assess nurses‟ (socio-demographic characteristics) factors that influence job satisfaction among nurses at the Greater Accra Regional Hospital. 2. To examine institutional factors that influence job satisfaction among nurses at the Greater Accra Regional Hospital. 3. To assess the level of satisfaction among the nurses at the Greater Accra Regional Hospital. 1.3.2. Research Questions The questions that helped to find answers to address the specific objectives were: 1. How do nurses‟ (socio-demographic characteristics) factors influence their job satisfaction at the Greater Accra Regional Hospital? 6 University of Ghana http://ugspace.ug.edu.gh 2. How do institutional factors influence job satisfaction among nurses at the Greater Accra Regional Hospital? 3. How can the level of job satisfaction among the nurses at the Greater Accra Regional hospital be assessed? 1.4. Outline of the dissertation The chapter one introduced the subject, problems of job satisfaction, justification to the topic, objective of the research and questions that were investigated among the nurses at the Greater Accra Regional Hospital. The chapter two presents literature review and the conceptual framework of the study. In chapter three, the methods that were applied to collect empirical data for analysis have been indicated. In chapter four, the results of the study have been presented. In chapter five, the results of the study have been related to existing literature. Finally, in chapter six, the summary, conclusions and recommendations of the study have been shown. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 2.0. Introduction This chapter presents the review of literature of related studies on the concepts underlying this study. There are five sections discussing job satisfaction; factors influencing job satisfaction, socio-demographic characteristics, institutional factors, conceptual framework and chapter summary. 2.1. Job Satisfaction Different authors have totally different approaches to the definition of job satisfaction, however this can be the foremost cited definition of job satisfaction: Job satisfaction is describe as the extent to which individuals like (satisfaction) or dislike (dissatisfaction) their job (Spector, 1997). This definition suggests that job satisfaction may be a general or global emotive reaction that people hold regarding their job. Some further argued that satisfaction is subjective and may solely be determined by the person experiencing the phenomenon, although there is a general assertion to the present subject (Kucharska, 2017). Job satisfaction is the key ingredient that leads to recognition, income, promotion and also the accomplishment of different goals that result in a sense of fulfillment (Kaliski, 2007). Meanwhile, some also described satisfaction as more of a journey which has indefinite results, rather than a destination, as apply to employer, the health worker and the patient since there is no absolute way of measuring job satisfaction (Seckler, 2016). However the emphasis of this subject of job satisfaction is the fact that people acquired or rewarded adequately for the work they are entrusted to do (Johnson, 2015). There are many aspects involving this subject of job satisfaction, this is according to what each person or individual recognizes first as important to him or her. In several ways, the 8 University of Ghana http://ugspace.ug.edu.gh term 'reward' alone might totally mean different thing to different people, and how content or gratify somebody is with their job and also the sense of accomplishment achieved (Rafiq, Javed, Khan & Ahmad, 2012). Reward may take a physical or intangible form just like the feeling a personal gets after accomplishment of any job that profit others (Seckler, 2016). Reward may even be recognized as a status that a personal achieves for doing a particular job such as a lawyer or a doctor. The emphasis is to apply a proper reward or actual payment to the individual that is receiving it (Eerde, 2015). An example of rewarding a nurse for a decent job done aside her salary may not be monetarily, appreciation from her patients in the form of „thank you‟ may well be accepted. In some cases, it may be in a form of opportunity to be promoted to a higher rank in the organization (Sarwar, & Abugre, 2013). 2.2. Factors influencing Job Satisfaction Job satisfaction is multi-facet with many definitions and theoretical frames (Friend, Johnson, Rutherford, & Alexander Hamwi, 2013). Traditional model of job satisfaction was focused on individuals‟ feeling about their job (Crossley, Bennett, Jex, & Burnfield, 2007). Yet, being satisfied does not only rely on the type of job, but also certain attributes that enhances an individual fulfillment (Healy & McKay, 2000). This literature review is focused on the socio-demographic characteristics and the institutional factors that influence job satisfaction. That is, nurses‟ job satisfaction is very essential to health care organizations and their sources of satisfaction is relatively similar globally (Bhatnagar, 2012). For example, the working environment, team work, supervision, promotion, remuneration, responsibility, working hours and recognition among others, as well as socio-demographic characteristics of the nurses, such as age, sex, marital status, educational level, rank, salary range, among others, have influence on job satisfaction among the nurses. 9 University of Ghana http://ugspace.ug.edu.gh 2.3. Nurses’ Factors /Socio-Demographic Characteristics of the Nurses It is expected that the socio-demographic characteristics of nurses could influence their perception of job satisfaction (Asegid, Belachew, & Yimam, 2014). The discussion below focuses on key variables that could influence job satisfaction among nurses. 2.3.1. Age Rafferty et al., (2007), found that one third of nurses below age 30 years intended to quit their job within 12 months due to job dissatisfaction in the US, Scotland, England, Germany. This was because of the empirical evidence that nursing job is very stressful and the younger and inexperienced one is, they are more likely to become worn out and do the work any how or quit as a result of dissatisfaction. Other studies argue that in the western world, there is more satisfaction among the older nurses than the younger ones as a result of the perk that goes with long career, including higher salary, better benefits and success from the job achievements (Beckett & Taylor, 2016). However, in the part of world where Ghana is located, there is less recognition that goes with the job in terms of achievements and self- actualization, after working for so long till retirement (Maslow, 1954). Many research have proven that age has correlation with job satisfaction, but others still argue that, it is the least since they conclude that the biggest differentiator is the reward in the form of wages and salaries that goes with longer stay thus retention and not the actual age of the individual - that is, the move with longer service (S. Burks, Carpenter, & Goette, 2009). Nursing job as indicated earlier is stressful and also has effect on the social life of the nurses. This shows that when nurses are in their youthful age, they would have liked to enjoy life by socializing as their counterparts in other professions do. But due to irregular nursing work schedule, the young nurses are not able to socialize, they are almost always stressed up with the job and all these lead to job dissatisfaction since nurses do not manage their own time, but 10 University of Ghana http://ugspace.ug.edu.gh rather the work that dictate their next line of action. All these contribute to their satisfaction or dissatisfaction level in relation to age (Gulavani & Shinde, 2014). According to Locke, Cartledge, and Knerr, (1970), there is strong correlation between age and job satisfaction. Present research showed that there is a strong correlation between age and job satisfaction even though other studies have different view (Garcia, Solano-Ruiz & Martinez-Roche, 2013). A survey was done in the US and only 45% of the younger people below age 30 years indicated satisfied with their work and about 95% of the older people reported being satisfied with their employment. The high job dissatisfaction among the young people was tied to unrealistic expectations and also most companies resistant to change, which usually frustrated with co-workers of the young people who were satisfied with mediocrity (thus being content with where they are) while the older people‟s satisfaction was linked to the perks that have to do with maintaining a long career, including high salary, benefits and respect (Burks, 2011). Age was also explained as chronological age as in numbers of the age of an individual and subjective age as number of years spent with a job. In a research, subjective age was more related to job satisfaction as compared to chronological age (Cortese, Colombo & Ghislieri, 2010). Many investigators have examined the relationship between age and job satisfaction. However, many reported negative linear whilst others positive linear or no significant relations. Such conflicting results have left the true nature of the relationship unsolved. Age failed to explain a substantial proportion of linear variance in job satisfaction measure (Saner & Eyupoglou, 2012). Perhaps, depending on the context and the issue at stake, many research found age to be significantly correlated to job satisfaction and few found it to be insignificantly related perhaps due to the tools used in measuring job satisfaction. 11 University of Ghana http://ugspace.ug.edu.gh 2.3.2. Sex Most of the men who enter into nursing aspire to enter into the medical school as a continuum without knowing that the two professions are not the same and when the situation does not go their way, they tend to be disappointed, frustrated and dissatisfied with everything about the nursing profession coupled with unmet desires and expectations (Tekindal, Tekindal, Pinar, Ozturk, & Alan, 2012). Nursing is still seen as a predominantly feminine profession, especially in Africa where care is associated with women (Anchora, 2016). All these frustrations in addition to low salary, lack of incentives will lead to job dissatisfaction (Nyirenda & Mukwato, 2017). Literature concerning sex differences in job satisfaction typically finds that despite having lower pay and fewer opportunities for advancement, women find satisfaction with their job more than men (Ford, 2008). This may be as a result of bigger aspiration of men, differences in values and high expectation as compared to women (Hirsch & Rapkin, 1986). Nursing profession is women domineering and as such the women hold high positions in the profession (Li & Lambert, 2008). This usually tend to put pressure on the men because most women in higher positions tend to put lots of pressure on their subordinates further frustrating the men also leading to job dissatisfaction (Blaauw, Ditlopo, Maseko, Chirwa, Mwisongo, 2013). In another study, men appeared well adjusted and content in their roles and lives, had no conflict between work and family, social support, confidence in work skills and confidence in physical and emotional expression with other men, which suggested more men should be recruited into nursing even though women have been identified to be more satisfied with their job as compared to men (Garcia, Ruiz, Roche & Gomez, 2013). This may differ in the African context where there are stereotypes, fewer job incentives and no better condition of service for the nurses, which mostly deter the male nurses from moving along or progressing 12 University of Ghana http://ugspace.ug.edu.gh further in nursing (Li & Lambert, 2008). Another research concluded that women health workers in general are more satisfied with their job as compared to men health workers (Garcia et al., 2013). Therefore, it was suggested that policies should focus on taking action to correct the conditions that create satisfaction/dissatisfaction among certain groups of employees than the other (Garcia et al., 2013). 2.3.3. Marital Status Marital status of an individual employee should be a matter of concern since man is a social being and as such must fulfill a social responsibility (Aiken, Sloane, Bruyneel, Van den Heede, & Sermeus, 2013). Nevertheless, due to work pressure and unfriendly schedule at work, it affects most nurses‟ marriages and by the time these nurses grow, more than 60% of them become divorced and at times single parents due to role conflict and role ambiguity (Gormley, 2011). A lot of men cannot stand home pressure while their partners are on odd job schedules such as night-duties, holiday schedules and weekend duties, especially when these do not attract any extra income and motivations (Liu et al., 2012). Contrarily, in the western world unlike a developing country like Ghana, such odd duties attract high incentives and rewards (Li & Lambert, 2008), so that though the partner may not be in the house to fulfil other needs, they may use the extra income gained from the additional duty to compensate for other home needs. Previous research indicates that there is a certain degree of correlation between marital status and job satisfaction, but specifies that marital status correlate more in older men (middle age men) than young men and women since middle age men tend to value marriage as a prerequisite for life satisfaction (Locke et al., 1970). 13 University of Ghana http://ugspace.ug.edu.gh Sometimes, there is also family and other social conflicts with nurses and their job because nurses working in hospitals are not usually able to attend social functions such as marriage ceremonies, funeral and others, which the society put more value on as Ghanaians. Nurses‟ inability to attend such functions puts pressure on their partners to fulfil such obligations and all these affect the social life of the nurses and double role function on their partners, which are usually converted into compensations elsewhere (Ramoo, Abdullah, & Piaw, 2013). In spite of all the insight given above, there was an indication that married nurses are more satisfied with their job than single nurses. This might be as a results of inner satisfaction that come with marriage due to partner support system (Olatunji, Mokuolu & Bolade, 2014). 2.3.4. Position and Rank Research have shown that employees in higher positions in organizations have some higher level of job satisfaction than those in lower positions (Morello, 2011). Morello (2011), maintains that those in the higher positions have long career thus experience, high salary, better benefits and success in the work. Additionally, work processes for those in higher positions are a little flexible since they mostly delegate activities to the junior members (Morris & Blanton, 1994). Satisfaction has been identified to be associated with performance (Landeweerd & Boumans, 1994). So, it is not strange that job satisfaction has gained much popularity in the western countries (Landeweerd & Boumans, 1994).Brown, Gardner, Oswald, and Qian, (2008), observed that employees‟ position in an organization had a strong link with job satisfaction. Rank was found to influence how proud workers were with their achievements and successes. There was an indication that, rank increases happiness from 50% to 60% when compared with other factors - the position of an individual determines how powerful a person is in an organization (Lunenburg, 2012). Therefore, workers are always doing all they could to move from one 14 University of Ghana http://ugspace.ug.edu.gh rank to the other. Individuals need power to influence organizational members to act according to their wish and to put in place processes toward achieving organizational goals (Hartzell & Starks, 2003). Nursing profession like many other professions, accords lots of regard to the rank and file and as long as one reaches a certain position/rank, a certain amount of respect is automatically accorded regardless of the person‟s age (Lunenburg, 2012). Because of that, many nurses prefer to chase after this factor to achieve their individual satisfaction instead of negotiating for better general conditions of service, which they find it difficult to achieve. Nurse leaders have higher job satisfaction than the junior nurses (Lober & Savic, 2012). 2.3.5. Level of education Traditionally, nursing education was not so high, tracing back to Florence Nightingale‟s days (Dossey, 2005). But in this sophisticated era and modernization, level of education is so crucial right from the recruitment level to the last post to retirement (Price & Reichert, 2017). Nowadays, there are nurses, who have attained their Doctor of Philosophy (PhDs) degrees and even at the professorial level, who are mostly in the classroom educating the young ones. Although the individual‟s high level of education may give a sense of accomplishment, what is not clear is how this translates to their achievement (Saba, 2011). Research indicated that individuals who have attained higher levels of education were more likely to achieve satisfaction with their jobs than those with low level of education due to certain perks such as recognition and benefits attached to high education at the work place (Gupta, 2008). Nursing education is very important and correlate with job satisfaction because the scientific base in nursing must be understood by the person rendering the service in order to relate actions to achieve holistic care (Duffy, 2009). Without the scientific approaches and methods, any service rendered by a nurse is considered general service (DHS, 15 University of Ghana http://ugspace.ug.edu.gh 2008), which can be done by any ordinary person. This is why nursing education is very crucial in order to make informed decisions and choices in rendering quality nursing care. And the higher the education level of the nurse, the more informed he/she becomes, which makes him or her more competent and self-actualized in the profession (Christie, Miller, Cooke, & White, 2015). Research done in Saudi Arabia confirmed that there were significant differences in job satisfaction across age, sex, years of experience, educational level, rank and others (Maghradi, 1999). 2.4. Institutional Factors influencing Job Satisfaction There are some institutional factors that could have considerable influence on job satisfaction among nurses. Some of these have been explained below. 2.4.1. Policies Policy is a backbone of an organization (Cummings & Worley, 2013). Health policy is involved in analysing health laws, regulations and public policies and strategies and advocate for policy changes, plan and implement new policies in healthcare (Sharma, 2017). Human resource policies and job satisfaction have been studied extensively and concluded that human resource policies are closely related to job satisfaction (Maicibi, 2013). A well written and sound human resource policies result in job satisfaction (Kwenin, Muathe, & Nzulwa, 2013), and consequently, patients‟ quality care. Organisations that examine their human resource needs are more likely to succeed than those that do not analyse their human resource needs (Harcourt, van Beek, Heslop, McMahon, & Donovan, 2001). Analysing employees‟ satisfaction needs offer a better chance of increasing organizational performance (Latif, Ahmad, Muhammad, Ferdoos, & Naeem, 2013). A well-defined policies and well 16 University of Ghana http://ugspace.ug.edu.gh managed human resource policies will enhance organizational efficiency and effectiveness (Kwenin et al., 2013). Institutions that offer special treatment and or selective human resource policy among staff instigate staff demonization and organizational inefficiency (Gupta, 2008). If human resource policies are fair and equitable, employees will be satisfied (Gupta, 2008). Policies in human resource management should be examined closely in every organization for policy implementation of other policies to achieve organizational goal (Vermeeren, Kuipers, & Steijn, 2014). Good policies of an organization are neither too rigid nor flexible and require frequent review and monitoring (Pule, Mwesigye, Kanyangabo, & Mbago, 2014). Several research done in the past made suggestions to strengthen organizational policies to increase job satisfaction among health workers, especially nurses due to increasing need for best possible care supply in order to increase quality of service (Andrioti, Skitsou, Kalsson, Pandouris, Krassias, 2017). 2.4.2. Supervision Supervision is vital to job satisfaction (Perchal, Odingo, & Pavin, 2011). The type of a leader or supervisor at the work place can help or destroy the entire structure and success of the organization (Harcourt et al., 2001). Supervisors and all leaders should treat their subordinates with the individualistic view of man (Lunenburg, 2012). Research has demonstrated that effective supervision is associated with job satisfaction, commitment to the organization and retention (Carpenter, Webb, Bostock, & Coomber, 2012). A supervisor should be able to create a friendly atmosphere at the work place. A supervisor should not be too rigid, but should be firm and flexible to work with. And by doing all these, subordinates will be happy to be at work since they have achieved job satisfaction (Porter, Wrench, & Hoskinson, 2007). 17 University of Ghana http://ugspace.ug.edu.gh Leader-member exchange theory tries to understand the quality of each relationship and its effects on organizational outcome (Sonfield & Lussier, 2004). Nursing supervision had been very rigid in the past and with the current generation and contemporary nursing, that type of leadership style had failed to answer the question of job satisfaction (Wallace et al., 2016). Abusive supervision, which contradicts ethical supervision results in a negative influence on job satisfaction, and in turn influences intentions to quit as well as increases turnover in the hospital (Palanski, Avey, & Jiraporn, 2014). Transformational and transactional leadership styles of nurse managers were positively related to nursing job satisfaction. According to Borman and Abrahamson (2014), transformational and transactional leadership style should be thought and encouraged among nurse managers to positively influence their job satisfaction (Bormann et al., 2014). Current research indicates that effective and efficient supervision results in job satisfaction and subsequently, quality of care (Hashish, 2012). 2.4.3. Teamwork Teamwork has been associated with a higher level of job satisfaction (Chang, Ma, Chiu, Lin, & Lee, 2009). Nursing work is about coordinating activities among other team members (Temkin-Greener, Cai, Zheng, Zhao, & Mukamel, 2012). It is impossible to achieve nursing goal without effective collaboration of teamwork (Bedward & Daniels, 2005). Nursing success and adequacy is about teamwork, correlating with job satisfaction, which is embodied with team training, effective communication, facilitating activities, identification of shared values, and good interpersonal relationship (Kalisch, Lee, & Rochman, 2010). A study assessed the relationship between staff characteristics and teamwork and job satisfaction in the USA (Sørensen et al., 2013). The conclusion was that team work was highly correlated with job satisfaction because increased teamwork would lead to safer and 18 University of Ghana http://ugspace.ug.edu.gh high quality of care (Kalisch et al., 2010). It was suggested that nursing management should make the effort to improve teamwork to impact on job satisfaction (Kalisch et al., 2010). Effective communication in ascending and descending order and also good interpersonal relationship will facilitate quality care at the hospital. A study conducted to determine the association between teamwork and job satisfaction and showed that lower levels of job satisfaction as a result of teamwork, subsequently, contributed to higher psychological distress of an employee (Harrisson, Loiselle, Duquette, & Semenic, 2002). Results of a recent study pointed out the need to focus on nursing team work on client care unit and recommended seven evidence-based strategies to develop, enhance and sustain successful team training, which include: alignment of team training objectives and safety aims with organizational goals, providing organizational support, encouraging participation of frontier leaders, effective training of the staff and the environment for team training, determination of resource and require time commitment, facilitation of application of acquired teamwork skills and measurement of the effectiveness of the team training programme (Zong-Xia Chang, Gui-Hua Yang & Yuan, 2014). Kalisch and others did a work on job satisfaction, and showed that teamwork and adequate staffing could lead to greater job satisfaction (Kalisch et al., 2010). 2.4.4. Promotion Promotion and recognition have been proven to be closely related to job satisfaction (Mayhew, 2015). One way promotion enhances job satisfaction is by providing an opportunity for increased compensation and benefits (Mayhew, 2015). Usually, promotions include more responsibility for the employee to be consistent and task oriented to produce high quality of work (Haynie, Hartman, & Lundberg, 2007). Promotion in nursing profession is usually not by merit, but mostly given according to the number of years served in addition 19 University of Ghana http://ugspace.ug.edu.gh to level of education according to the policy at hand (Price & Reichert, 2017). Naturally, when employees are promoted in an organization, it creates loyalty and enthusiasm, which will all lead to job satisfaction (Mangset, Maxwell, & van Zanten, 2017). Promotion is also an important aspect of a worker‟s career and life. The wellbeing of a worker is for the individual to climb the ladder of his or her profession (Mayhew, 2015). Research have shown that employees value promotion and even the expectation that one would be getting promotion in the next couple of years would encourage them not to quit a job (Kosteas, 2009). In recent times, the British National Health Service (BNHS) experienced an acute shortage of qualified nurses and therefore, made recruitment and retention of nurses a high priority on the national agenda (Shields & Ward, 2001). Studies were done at the national level and the result was that, most nurses were not happy as a result of job dissatisfaction. The nurses reported on delayed promotion, lack of incentives, low salary, lack of recognition, among others, as compared to other public workers. Strategic plans were made to correct the anomaly to save the situation by promoting the above variables (Asegid et al., 2014). However, dissatisfaction with promotion and training opportunity was found to have had a stronger impact than workload and pay (Shields & Ward, 2001). 2.4.5. Motivation Motivation can be described as the desire within a person to do something (McLaughlin, Moutray, & Moore, 2010). Another definition is the process of stimulating individuals to action to accomplish a specific goal. Motivation is: „psychological forces that determines the direction of a person‟s behavior in an organization, a person‟s level of effort and a person‟s level of persistence‟ (Bright, 2008)]. Keeping staff driven could be a task that managers can 20 University of Ghana http://ugspace.ug.edu.gh resolve in a very variety of ways (Bright, 2008). Because some form of motivation does not even cost so much (Rupp & Mallory, 2015). Sometimes, it is just a word of appreciation, praises or just something small (Lin, Ramakrishnan, Chang, Spraragen, & Zhu, 2013). When employees are not motivated and dissatisfied, they tend not to pursue additional task and not show any commitment, which tend to hinder the growth of an organization (Salman, Mahmood, Aftab, & Mahmood, 2016). When nurses are dissatisfied with their job, they also tend to be unconcerned about certain decisions at the hospital and this attitude endanger the life of the patient (Ulrich, Lavandero, Woods, & Early, 2014). There is a definite relationship between motivation and job satisfaction, because employees‟ commitment is enhanced when they are motivated even though motivation vary in different forms (Mooney, Harris, & Ryan, 2016). When employees feel motivated and satisfied with their job, they become enthusiastic, content and work efficiently to achieve the organizational goal. Many managers believe that employees are better motivated by the prospects of job satisfaction than other factors of job satisfaction (Breslau, Novack, & Wolf, n.d.). Goal– setting theory suggests that specific and tough goals cause high motivation and success. And equity theory conjointly specifies that managers ought to promote high levels of motivation by guaranteeing folks believe the result (Ramlall, 2004). All these shows that organizational success is dependent on employees‟ motivation (Bushra, Usman, & Naveed, 2011). Herzberg‟s (1959), theory of motivation, explains how motivation influences performance of employees at the work place. 2.4.6. Remuneration A study showed that the more satisfied and happier staff were with their job duties and level of compensation, the high probability that they will stay with their employment (Parvin & 21 University of Ghana http://ugspace.ug.edu.gh Karbin, 2011).One of the assertions of job satisfaction is when salary is too low, it is more likely that an employee will become frustrated and not able to do their best for the organization and eventually will leave the organization for the one with a better remuneration (Cheng et al., 2012). This shows how important salary and reward determine a person‟s choice of employment. From the literature reviewed, it was realized that other factors of job satisfaction such as age, experience, position and others were linked to the remuneration factor (Bakotić, 2016). Most employees, especially nurses have severally resorted to strikes at the expense of the ordinary patients due to a fight for better condition of service and better remuneration (Skinner, Madison, & Humphries, 2012). Highly paid organizations often retain workers more than low income earning companies because when the incentives are not enough to improve the standard of living of the individuals, the workers would not be happy and will resort to something different, either they would fight it or leave the organization to where they would be treated fairly (Mabaso, 2017). In the Ghanaian setting, where employment is difficult to change due to high unemployment rate (Agyepong et al., 2004), some employees find it difficult to change their job and will remain and pretend to be working, which retards the progress of the organization as a result of job dissatisfaction. Compensation plays a vital role in attracting and retaining highly skilled employees (Ahmad et al., 2016). Evidence from previous studies showed that compensation had a strong influence on job satisfaction (Mabaso, 2017). The gaps in the literature were addressed in this study, especially with reference to the nurses‟ job satisfaction at the Greater Accra Regional Hospital. 22 University of Ghana http://ugspace.ug.edu.gh 2.5. Conceptual Framework Based on the above discussed literature, the conceptual framework of the study was developed. The conceptual framework in figure 2.1 explains how the institutional factors, which are the policies of the organization, supervision, teamwork, promotion, motivation, remuneration; and nurses‟ factors / socio-demographic characteristics of the nurses which are the age, sex, level of education, marital status, income, rank and experience influence job satisfaction among the nurses at the hospital. The two main factors are the independent variables and the main outcome/ dependent variable is job satisfaction. In stitutional Factors: Nurses factors/socio- Policies demographic characteristics: Supervision T e a m w o r k Age Job Satisfaction Sex P romotion Level of education M otivation Marital status, Remuneration Income, Rank, Experience Figure 2.1: Conceptual Framework of factors influencing job satisfaction among the nurses The study of job satisfaction became more popular with the introduction of Herzberg‟s two- factor theory also known as motivator hygiene theory (Herzberg, 1966). The study views an individual job as a principal source of job satisfaction in contrast to Maslow‟s earlier theory of motivational hierarchy of needs, which identifies five levels of needs with basic needs 23 University of Ghana http://ugspace.ug.edu.gh emerging as first and the complex needs of self-actualization as last (Baaren & Galloway, 2014). Herzberg‟s motivation theory describes the concept of job satisfaction with two dimensions: Intrinsic factors and Extrinsic factors. The intrinsic factors are known as motivators and the extrinsic factors also known as hygiene‟s factors (Iqbal, Hameed & Ramzan, 2012). The motivators signifies to the job content or job itself, which include achievement, recognition, work itself, responsibility and advancement. The hygiene factors are also related to job context or the work environment involving the organizational policy and administration, supervision, salary, interpersonal relations or teamwork and working conditions (Baaren et al., 2014). The theory further explains that motivators are related to job satisfaction when present but should not lead to dissatisfaction when absent (Soomro, Hameed & Hameed, 2012). Herzberg‟s motivational theory is a foundational theory on the study of job satisfaction, which allows for the conceptual understanding of work and how it motivates and provide satisfaction for employees (Goff, 2004). 2.6. Chapter Summary This chapter has examined literature on the key themes/concepts underpinning the study. It has shown that job satisfaction as a dependent variable could be influenced by several factors, including nurses‟ (socio-demographic characteristics) factors; and institutional factors. Based on the gaps identified in the literature as lack of good organizational structures link to lack of organizational and individual commitment to achieve quality care. The conceptual framework of the study was developed to establish the relationship between the dependent and independent variables of this study. The next chapter presents the methods applied to collect data for subsequent analysis. 24 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.0. Introduction This chapter provides a quick background to the study style, analysis setting, study population, inclusion and exclusion criteria, sampling ways, sample size determination, dependent and freelance variables, information assortment technique, form style and administration, information analysis, moral issues, respondents‟ consent and therefore the outline of the chapter. 3.1. Study Design This study used a cross-sectional design and a quantitative method to collect data from the nurses on their socio-demographic characteristics and the institutional factors that determine their job satisfaction. Quantitative research strategy was applied because it seeks to systematically and scientifically measure the relationship between variables in order to support or reject some hypotheses (Silverman, 2013). A cross-sectional style may be a form of empirical study that involves the analysis of knowledge collected from a population, or a representative set, at one specific purpose in time (Schmidt & Kohlmann, 2008). During this technique, the investigator records info regarding their subjects while not manipulating the study atmosphere. It will compare totally different population cluster at one purpose in time. Quantitative analysis style may be a systematic method of getting quantitative info regarding the planet bestowed in numerical type and analysed through the employment of statistics to explain and take a look at relationships (Grove, Burns, & Gray, 2013). Quantitative research was a choice here because it focused on data analysis of great numbers of the nurses at the hospital and also tested the relationship between the variables. 25 University of Ghana http://ugspace.ug.edu.gh 3.2. Study Location/Area The study was conducted at the Greater Accra Regional Hospital, which serves as a learning centre for various universities and also a referral centre for other district hospitals and health centres in the region. It has all the various departments in a tertiary institution except few special areas such as cardiothoracic centre, oncology and plastic surgery departments, which are often referred to the Korle- Bu Teaching Hospital and sometimes the 37 Military Hospital (GHS, 2014). The Greater Accra Regional Hospital (formerly known as Ridge Hospital) is sited within the Osu Klotey Sub-Metropolitan (OKSM) Assembly, which is one of the fifteen sub-metros in Accra. The others are Okaikoi, Ashiedu Keteke, Ayawaso, Kpeshie, and Ablekuma. The Osu Klotey Sub-Metro (OKSM) is one of the eleven (11) Sub-metropolitans of the Accra Metropolitan Assembly (AMA) mandated by Legislative Instrument 1615 (LI 1615), amended by Act 1722 of 2003 and LI 1926, 2007 (GHS, 2014). OKSM lies in the south eastern part of the Accra Metropolis. It is bounded to the south by the Atlantic Ocean from Osu through the Independence Square to the Accra Arts centre through Kinbu, Management of Trade Transport Union (MTTU), and to the Graphic Road Crossing. It is bounded to the east by La Sub-Metro; Ring Road east from the La Bridge to Okodan Road crossing to the sea. It also shares boundaries to the North by Ayawaso Sub-Metro, from the Odaw Bridge end to the Ring Road central at Kwame Nkrumah Circle with Okaikoi and to the west by the Ablekuma Sub-Metro Assembly. OKSM had a total population of 121,723 as at 2010 (GSS, 2010). There are eight private and five public health facilities in the Osu Klotey Sub-Metro. The Greater Accra Regional Hospital is one of the public health facilities. It is located on the Castle road opposite the Valco Trust House. It occupies a total land area of about 15.65 acres. It is the Greater Accra Regional Hospital and has enjoyed that status since 1996 (GSS, 2010). It was built in 1912 by an European Mining Company. It used to be a hospital solely for the 26 University of Ghana http://ugspace.ug.edu.gh white man and his relation (GSS, 2010). The hospital was turned into women`s hospital to treat Obstetrics and Gynecological cases. Straight midwives were admitted and trained on the job (GSS, 2010). The hospital was later turned into a district hospital in 1974 during the era of the late Col. I.K. Acheampong. The catchment area is the whole of Accra with an estimated population of over 4,010,054 (GSS, 2010). The immediate areas include, Nima, Maamobi, Kanda, Accra Newton, Kotobabi, Osu, La, Adabraka, Achimota and Central Accra. The hospital provides both inpatient and out-patient care with a bed capacity of one hundred and ninety-one (191) as at the end of May, 2017, before moving into the new edifice with bed capacity of four hundred and twenty (420) to be increased later to six-hundred (600). The staffing position stood as: nurses (520), doctors (280), and about 30 different units of allied health professionals (Awuah, 2017). Health care is financed through the cash pay for service system, internally generated fund, the National Health Insurance Scheme and private insurance system. 3.3. Study Population A study population, according to Kerlinger and Lee (2000), is all components, that is, people, objects or substances that meet a precise criteria for inclusion in an exceedingly given universe. The target population that represented in this study included all skilled nurses who were permanently working at the Greater Accra Regional Hospital at the time of the data collection for the study. 3.3.1. Inclusion Criteria The inclusion criteria involved all full time employed categories of professional nurses at the Greater Accra Regional Hospital who had worked continuously for more than two (2) years and above. The rationale behind this was to get responses from experienced nurses as well as from all levels who were well-informed about their work and the place. 27 University of Ghana http://ugspace.ug.edu.gh 3.3.2. Exclusion Criteria The study excluded all categories of other health workers who were not nurses, nurses who were on study leave or sick leave, and other supporting staff who were working directly on the patients, but were not nurses. 3.4. Study Variables The variables that were assessed in the study were divided into dependent and independent as provided below. 3.4.1. Dependent variable The dependent variable was Job satisfaction. 3.4.2 Independent variable The independent variables were: Nurses ‘factors/socio-demographic characteristics; age, sex, marital status, rank, level of education, income and experience. Institutional factors: policies, supervision, teamwork, promotion, motivation, remuneration. Description of the study variables The overall job satisfaction, which was the dependent variable, was measured using „yes‟ and „no‟ response to the questions. However, the independent variables were measured using responses to the questions on the nurses‟ own socio-demographic characteristics; and the institutional factors were measured using the responses to the Likert Scale type questions. The answers were: strongly disagree =1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5. The scores were added up to give the total scores by the respondents on highly satisfied or low satisfied. Respondents who scored between strongly agreed and agreed were 28 University of Ghana http://ugspace.ug.edu.gh highly satisfied, those who were neutral were moderately satisfied and those who scored between strongly disagreed and disagreed were classified as having low satisfaction. The description has been outlined in table 3.1 below. 29 University of Ghana http://ugspace.ug.edu.gh Table 3.1: Description of the study variables NO Variable(s) Measurement and Score Range Dependent Variable Yes Job Satisfaction No Independent Variables Numerical Socio-demographic Characteristics Institutional Factors Policy Strongly disagree, disagree, neutral, agree, strongly agree Supervision Strongly disagree, disagree, neutral, agree, strongly agree Promotion Strongly disagree, disagree, neutral, agree, strongly agree Teamwork Strongly disagree, disagree, neutral, agree, strongly agree Motivation Strongly disagree, disagree, neutral, agree, strongly agree Salary Strongly disagree, disagree, neutral, agree, strongly agree 3.5. Sampling Method The study participants were selected using a simple random sampling technique (Bobko, Miller, & Tusing, 1980). Bobko et al. (1980), explain that simple random sampling is a subset of statistical population in which each member of the subset has an equal probability 30 University of Ghana http://ugspace.ug.edu.gh of being chosen at any stage of the selection process. This selection was done by obtaining the list of all category of nurses from the nursing administration of the hospital, and applied „yes‟ and „no‟ to the list and selected randomly all the „yes‟. This method was used to obtain the accurate results since the list of all the nurses was readily available at the nursing administration and this method helped reduced bias and any suspected error. Simple random sampling technique was used in this study because it is the best method to apply to minimize errors and biases when a researcher has access to the entire population understudy. 3.5.1. Sample Size Determination The sample size calculation was based on the assumption that the current number of 530 nurses at the Greater Accra Regional Hospital remained unchanged at the time of the data collection. Therefore using finite sample size formula by Yamane 1967, where: n: sample size N: the population size of the nurses at Greater Accra Regional Hospital, N=530 e: precision, 5% (0.05) Inputting the above into equation (1), the minimum sample size for required for this study was calculated as : Therefore the final minimum sample size needed for this study was 228. 31 University of Ghana http://ugspace.ug.edu.gh 3.6. Data Collection Technique: Questionnaire Design and Administration A structured questionnaire was designed and administered to gather empirical data from the nurses so as to assess their job satisfaction. The structured questionnaire was designed according to the modified index of job satisfaction (Martins & Proenca, 2012), which had close ended questions – this was used to collect data on job satisfaction. The questionnaire was divided into sections. Section „A‟ collected information on the socio-demographic characteristics of the nurses. Section „B‟ also collected information about the institutional factors influencing job satisfaction. The questions were designed, coded using Likert scale type of questions and responses. The responses were set as: strongly disagree = 1; disagree = 2; neutral = 3; agree = 4; and strongly agree = 5. These forms of questions were used to measure the determinants of job satisfaction. The data collection tool was previously used to measure job satisfaction in Minnesota (Martins & Proenca, 2012). It was then modified to suit this study context. The questionnaire were distributed to the nurses with the help of research assistants at a general meeting organized by the Head of Nursing at the hospital in two subsequent meetings according to the list obtained from the nursing administration. This was done within two weeks from 01/05/18 - 15/05/18. The questionnaires were self-administered and were collected back after completion. 3.7. Data Analysis Data obtained from the questionnaires were entered into Microsoft excel and also transferred to Stata Version 15 for cleanup, merging and analysis. Cleanup of the information was done by running frequencies of the variables. This checked inconsistently coded information. Inconsistently coded information were double checked with data from the form. Each univariate and variable regressions were performed. Continuous variables were summarized as means that customary deviations whereas categorical variables like age, gender, marital 32 University of Ghana http://ugspace.ug.edu.gh status were summarized as frequencies and percentages. Two ways were used for the analysis of the Likert scale responses. Firstly, the answers were coded on a scale from one (strongly disagree) to five (strongly agree) and analyzed numerically. The composite score was calculated for the variables on job satisfaction. The composite mean was then calculated using Stata Version 15. The connection between the dependent variable (job satisfaction) and freelance/independent variables like sociodemographic characteristics (age, work expertise, gender, instructional level, etc.) and also the institutional/facility-related factors were analyzed at first using univariate (simple) rectilinear regression analysis. Multiple rectilinear regression analysis was done to exclude high intercorrelated independent/freelance variables. A mean of but three .00 (neutral) –in regard to the Likert scale was thought-about as low job satisfaction and a mean on top of neutral was thought-about as high satisfaction. A similar approach was employed in previous studies (Martins & Proenca, 2012; Shuttleworth, 2008). A confidence interval of ninety fifth was accustomed to show important relations between the dependent and also the freelance variables. Regression was used because the outcome variable (job satisfaction) was a continuous variable and is normally distributed. It has been explained that regression analysis generates an equation to describe the statistical relationship between one or more predictor variables and the response variable (Ogee et al., 2018). Ogee et al. (2018), indicate that the p-value for each term tests the null hypothesis that the coefficient is equal to zero (no effect). In addition, a low p-value (<0.05) indicates that the researcher could reject the null hypothesis. Moreover, a predictor that has a low p- value is likely to be a meaningful addition to the model because changes in the predictor's value are related to changes in the response variable. However, a larger (insignificant) p- value suggests that changes in the predictor are not associated with changes in the response. 33 University of Ghana http://ugspace.ug.edu.gh Normality was determined by using histogram and gladder commands in Stata version 15. The results were presented in frequencies, mean and percentages. 3.8. Pretesting Pretesting of the questionnaire was carried out on twenty-five (25) nurses at the medical department of the Greater Accra Regional Hospital. This helped to review the questionnaire in order to ensure consistency across board and make necessary corrections and adjustments. 3.9. Quality Assurance Quality assurance is to ensure accuracy in the study. That is to make sure that appropriate methods and technologies are used to control biases and minimized errors. In this study, only professional nurses were enrolled and also nurses of all categories who have worked at the hospital from two (2) years and above who have insight of the place. In addition, nurses who were not willing to participate were not coerced to do. 3.10. Validity and Reliability Validity is the extent to which the research instrument measures what it is supposed to measure while reliability refers to the consistency or stability of an instrument (Shuttleworth, 2008). In this study, validity and reliability were measured by pre-testing the questionnaire on twenty-five (25) professional nurses with similar characteristics as the sample population used in the study. The rationale behind this was to ensure how relevant the questions would respond to the objectives of the study and to help make necessary corrections. This proved extremely useful and helped in restructuring the research topic to include only experienced professional nurses. 34 University of Ghana http://ugspace.ug.edu.gh 3.11 Ethical Consideration Ethical issues involved in the study were addressed accordingly. Ethical approval for the study was sought from the Ethics Review Committee of the Ghana Health Service. A letter of introduction was sent from the School of Public Health to the Greater Accra Regional Hospital, through the Hospital Administrator and the Deputy Director of Nursing Services (DDNS) to seek permission to use the facility to conduct such a study. That is, an introductory letter stating the purpose of study and duration, from the Head of Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana together with a copy of ethical clearance from the Ghana Health Service attached, was sent to the Greater Accra Regional Hospital. The approval was also shown to all the heads of various departments, before the study began (see appendix D ethical clearance). Other activities to ensure that ethical issues were conformed to have been explained below. 3.11.1. Participant Consent A written informed consent with a thorough explanation were given to the respondents who participated in the study for their approval. Participants who required to willingly consent to participate in the study were made to sign the consent form accordingly (see appendix A). 3.11.2. Privacy and Confidentiality Participants were informed that privacy and confidentiality were assured so that no one could trace their root. 35 University of Ghana http://ugspace.ug.edu.gh 3.11.3. Risk and Benefits This study did not put any participant into any risk or burden. The participants only provided information to aid in the study, which policy makers will use to improve the nursing profession across board leading to quality health care delivery. 3.11.4. Compensation The study did not attract any form of compensation to the participants, but will help reform the nursing profession and impact on the patients‟ care, which is the main focus of health delivery. 3.11.5. Research Funding The study was for an award of Masters in Public Health degree at the School of Public Health, University of Ghana, Legon. Therefore, there was no third party sponsorship. The cost of stationary, printing, transportation, among others, were funded by the researcher. 3.11.6. Withdrawal from the study Participants were informed that, participating in the study was optional or voluntary and an individual who was not willing or interested could opt out since that could not have influenced the outcome of the study. 3.11.7. Data Storage Participants were assured that all information gathered would be kept confidential. The information will be stored on devices such as pen-drives and CD to be used for betterment of the hospital and improve quality care. 36 University of Ghana http://ugspace.ug.edu.gh 3.12. Chapter summary This chapter has presented the methods that were applied to collect empirical data for analysis. It has shown that the quantitative method used was appropriate in helping to assess factors that could influence job satisfaction among nurses at the Greater Accra Regional Hospital. The data collection instrument, which was adopted has also been referenced appropriately. The next chapter presents the results as obtained from the data analysis. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0. Introduction This chapter presents the findings of the study in accordance with the expressed objectives and analysis queries. The chapter is in four sections. Section one presents demographic characteristics of the respondents. Section 2 presents the assessment of institutional factors of nursing follow. Section 3 presents the link between job satisfaction and also the socio- demographic characteristics of the respondents. Section four presents the link between job satisfaction among the nurses and also the institutional factors and section 5 presents the chapter outline. 4.1. Demographic characteristics of respondents Table 4.1. presents the demographic characteristics of the 233 nurses surveyed in the study. Majority 193 (82.8%) of the respondents were females. More than half 142 (60.9%) of the respondents were in the age group (18-30) years followed by 57 (24.5%) for age group (31- 40) years while the least 10 (4.3%) were in the age group (51-60) years. and 30-39 years respectively. More than one-third 90 (38.6%) of the respondents had Diploma education while 70 (30.0%) had Bachelor‟s degree and the least 9 (3.9%) had master‟s degree. More than half 118 (50.6%) of the respondents were single while 101 (43.5%) were married. Almost half of the respondents 104 (44.6%) had 1-5 years of nursing experience while 18 (7.7%) had more than 20 years of nursing experience. Majority 125 (53.6) of the respondents had worked at the Greater Accra Regional Hospital (GARH) for 1-5 years followed by 71 (30.5%) of 6-10 years while 4 (1.7%) had worked there for more than 20 years. 38 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Socio-demogra1phic characteristics Variable Frequency (N=233) Percent (%) Sex Male 4 0 17.2 Female 193 82.8 Age group (years) 18-30 142 6 0.9 31-40 57 24.5 41-50 24 10.3 51-60 10 4.3 Level of education Certificate 64 2 7.5 Diploma 90 38.6 Bachelor 70 30.0 Masters 9 3.9 Marital status Single 118 50.6 Married 101 43.4 Divorced 14 6.0 Years of practice 1-5 104 44.6 6-10 74 31.8 11-15 15 6.4 16-20 22 9.4 above 20 18 7.7 Years of practice at GARH 1-5 125 53.6 6-10 71 30.5 11-15 19 8.2 16-20 14 6.0 above 20 4 1.7 39 University of Ghana http://ugspace.ug.edu.gh More than one-fourth 65 (27.9%) of the respondents were staff nurse/midwife while 46 (19.7%) were enrolled nurses and 33 (14.2%) were senior nursing/midwifery officers (Table 4.1.2). Most 168 (72.1%) of the respondents work for 8 hours a day while 65 (27.9%) work more than 8 hours a day. Almost half 116 (49.8%) of the respondents worked in a very heavy ward. Majority 172 (73.8%) of the respondents earn a salary of 1000GHS – 2000GHS a month (Table 4.1). Table 4.1: Socio-demographic characteristics Cont’d Variable Frequency (N=233) Percent (%) Position/rank Enrolled nurse 46 19.7 Staff nurse/midwife 65 27.9 Nursing/midwifery officer 35 15.0 Senior staff nurse/midwife 28 12.0 Senior nursing/midwifery officer 33 14.2 Principal nursing/midwifery officer 26 11.2 Hours of work per day 8 hours 168 72.1 Above 8 hours 65 27.9 Nature of the ward Very heavy ward 116 49.8 Heavy ward 87 37.3 Slightly heavy 30 12.9 Salary 1000 – 2000 GHS 172 73.8 2100- 3000GHS 58 24.9 3100GHS + 3 1.3 40 University of Ghana http://ugspace.ug.edu.gh 4.2. Assessment of job satisfaction Table 4. 2. presents the overall assessment on job satisfaction and the various dimensions of satisfaction in relation to the study. Overall, there was low satisfaction 2.9 (SD=0.6). There was low satisfaction with regards to the policies concerning nurses 2.9 (SD=0.7), promotion 2.8 (SD=0.9) and motivation 2.7 (SD=0.9) with remuneration 2.3 (SD=0.8) recording the least. However there was high satisfaction with teamwork 3.3 (SD=0.7) and supervision 3.6 (0.5). 41 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Assessment of job satisfaction Variable Observations Mean Standard Min Max deviation Policy 233 2.9 0.7 1.3 4.4 Teamwork 233 3.3 0.7 1.0 4.8 Supervision 233 3.6 0.5 1.9 5.0 Promotion 230 2.8 0.9 1.0 5.0 Motivation 229 2.7 0.9 1.0 4.5 Remuneration 229 2.3 0.8 1.0 5.0 Overall job satisfaction 233 2.9 0.6 1.0 5.0 4.3. Assessment of institutional factors that influence job satisfaction Respondents were asked to show within a range, whether they agreed or disagreed with certain statements in relation to institutional factors that influence their job satisfaction. The results have been presented below. 4.3.1. Assessment on policy The assessment of policy factors that influence job satisfaction of nurses at the GARH (Table 4.3.1) shows that more than half 119 (52.0%) of nurses disagreed that they get the opportunity to participate in policy making and implementation decisions. Additionally, close to half 101 (43.9%) disagreed that management listens and responds to their concerns. Further, 166 (72.2%) disagreed that the hospital has free medical services for nurses who work at the facility. In terms of opportunities to develop their career as nurses, only 109 (47.4%) agreed there are such opportunities. However close to half 101 (44.5%) agreed that there is an active quality assurance program. Additionally, 158 (65.8%) of the respondents agreed that the hospital grants study leave to nurses who want to attend short courses and seminars related to their field. However, more than half 150 (65.2%) of the respondents disagreed that there is adequate number of nurses at the hospital currently for the provision of 42 University of Ghana http://ugspace.ug.edu.gh quality healthcare. Further, 90 (39.5%) of the respondents disagreed that the hospital has occupational safety plan for nurses to avoid work –related diseases and occupational hazards. Table 4.3.1: Assessment on policy Assessment on Policy: Strongly Disagree Neutral Agreed Strongly Disagree d Agreed d Nurses get the opportunities to participate in 59 (25.8) 60 (26.2) 33 (14.1) 74 (32.3) 3 (1.3) policy making and implementation decisions at the hospital. The hospital management listens and responds 32 (13.9) 69 (30.0) 47 (20.4) 78 (33.9) 4 (1.7) to nurses‟ concerns. There is active quality assurance program for 20 (8.8) 36 (15.9) 70 (30.8) 84 (37.0) 17 (7.5) nurses at the hospital. The hospital has free medical services for 81 (35.2) 85 (37.0) 31 (13.5) 24 (10.4) 9 (3.9) nurses at the various units. There are opportunities available for nurses to 21 (9.1) 51 (22.2) 49 (21.3) 95 (41.3) 14 (6.1) develop their career. The hospital grants study leave to nurses 9 (3.9) 25 (10.8) 45 (19.5) 128 24 (10.4) (55.4) The hospital has readily available working 11 (4.8) 27 (11.8) 35 (15.3) 141 15 (6.6) resources (61.6) The hospital grants nurses the opportunity to 21 (9.1) 39 (17.0) 52 (22.6) 95 (41.3) 23 (10.0) attend short courses and seminars related to their field. There is adequate number of nurses to provide 87 (37.8) 63 (27.4) 32 (13.9) 40 (17.4) 8 (3.50) quality care. The hospital has occupational safety plan for 42 (18.4) 48 (21.1) 46 (20.2) 74 (32.5) 18 (7.9) nurses to avoid work-related diseases and occupational hazards. 4.3.2. Assessment on supervision Table 4.3.2: presents the assessment on supervision at the facility. Overall, majority 183 (79.2%) of the respondents agreed the supervisors usually give orientation in the ward on first arrival. Additionally, most 188 (81.4%) of them stated that their supervisors acknowledge 43 University of Ghana http://ugspace.ug.edu.gh and recognise their role in working as a team. Further majority 170 (74.2%) of the respondents agreed their supervisors tell them when their works need improvement. Similarly, 149 (63.9%) stated their supervisors encourage them to attend workshops and seminars when necessary. Likewise, more than half 126 (55.0%) agreed their supervisors help them to solve personal problems as a motivation for productive work. Overall, assessment on supervision recorded higher scores (Table 2). Table 4.3.2: Assessment on Supervision Assessment on Supervision Strongly Disagree Neutral Agreed Strongly Disagree d Agreed d Assessment on Supervision My Supervisor usually gives orientation in the 4 (1.7) 14 (6.1) 30 (13.00 119 64 (27.7) ward on first arrival. (51.5) S/he acknowledges and recognizes my role in 3 (1.3) 10 (4.3) 30 (13.0) 154 34 (14.7) working as a team. (66.7) My supervisor tells me when my work needs 5 (2.2) 16 (7.0) 38 (16.6) 132 38 (16.6) improvement. (57.6) My supervisor encourages me to attend 14 (6.0) 27 (11.6) 43 (18.5) 121 28 (12.0) workshops and seminars when necessary. (51.9) My supervisor helps me to solve personal 14 (6.1) 32 (14.0) 57 (24.9) 103 23 (10.0) problems as a motivation for productive work. (45.0) My supervisor is interested in my personal 11 (4.8) 31 (13.5) 48 (20.9) 119 21 (9.1) feelings, especially if it would affect my work. (51.7) My supervisor often coaches me on the job. 5 (2.2) 24 (10.4) 36 (15.7) 138 27 (11.7) 960.0) My supervisor interferes in my work most of 17 (7.5) 74 (32.6) 57 (25.1) 69 (30.4) 10 (4.40 the time. I find no difficulty in getting my supervisor 6 (2.6) 35 (15.1) 55 (23.7) 108 28 (12.1) approving my appraisal. (46.6) My supervisor always delegates activities that 1 (0.4) 26 (11.3) 44 (19.1) 125 34 (14.8) require my knowledge and skills for improved (54.4) service. 44 University of Ghana http://ugspace.ug.edu.gh 4.3.3. Assessment on Team work Table 4.3.3: presents statements and scores in relation to teamwork. More than half, 145 (61.9%) of the respondents agreed there was good interpersonal relationship among nurses and other health professionals. However more than one-fourth 27.9%) of the respondents disagreed that effective communication is not a problem among nurses at the hospital. Similarly close to one-fourth 51 (21.7%) disagreed there is effective coordination of activities in the various wards. However majority 157 (67.7%) agreed they have trust and confidence in their colleague nurses for quality health care delivery. More than one-fourth 68 (30.0%) disagreed there is adequate time and opportunity to discuss about patients with colleagues. Similarly, more than one-fourth 66 (29.0%) disagreed there is no interference of nurses‟ role in the health care delivery. 4.3.4 Assessment on promotion Assessment on promotion by the respondents is shown below in Table 4.3.4. Overall, almost half 101 (44.1%) of the respondents disagreed there is a fair promotion system in place for nurses working at the hospital. Similarly, more than one-third 87 (39.2%) disagreed the promotion comes with benefits and same proportion 87 (39.2%) were not satisfied with their last promotion. Close to half 102 (44.9%) disagreed their promotion was a basis for hardwork and job satisfaction. Majority of the respondents disagreed they work just for promotion and better salary. However, almost a quarter 78 (24.0) disagreed the appraisal system for promotion is transparent and fair. 45 University of Ghana http://ugspace.ug.edu.gh Table 4.3.4: Assessment on teamwork and promotion Assessment on Team work Strongly Disagree Neutral Agreed Strongly Disagree d Agreed d There is good interpersonal 11 (4.7) 38 (16.3) 40 115 (49.4) 29 (12.5) relationship among nurses and other health (17.2) professionals Effective communication is not a problem 14 (6.0) 51 (21.9) 53 104 (44.60 11 (4.7) among nurses in the hospital. (22.8) There is effective coordination of activities in 10 (4.3) 41 (17.7) 58 109 (47.0) 14 (6.0) the various wards. (25.0) I have trust and confidence in my colleague 3 (1.3) 35 (15.1) 37 129 (55.6) 28 (12.1) nurses for quality health care delivery. (16.0) Other health professionals collaborate 13 (5.7) 46 (20.1) 46 107 (46.7) 17 (7.40 effectively for timely and quality health care (20.1) delivery. There is adequate time and opportunity to 13 (5.7) 55 (24.3) 71 71 (31.4) 16 (7.1) discuss about patients with other colleagues. (31.4) I have no difficulty in getting contacts of my 10 (4.4) 40 (17.5) 41 120 (52.4) 18 (7.9) colleagues for a coordinated health care (17.9) delivery. There is mutual respect between nurses and 18 (7.9) 40 (17.6) 56 96 (42.3) 17 (7.5) other health professionals. (24.7) There is no interference of nurses‟ role in 17 (7.4) 49 (21.3) 61 91 (39.6) 12 (5.2) health care delivery. (26.5) Assessment on Promotion: There is a fair promotion system in place for 56 (24.4) 45 (19.7) 37 73 (31.9) 18 (7.9) nurses working at the hospital. (16.2) Promotion of nurses comes with benefits. 36 (16.2) 51 (23.0) 44 76 (34.2) 15 (6.8) (19.8) You were satisfied with your latest 36 (16.2) 51 (23.0) 44 76 (34.2) 15 (6.8) promotion. (19.8) Nurses promotion is a basis for hardworking 53 (23.3) 49 (21.5) 43 61 (26.8) 22 (9.7) and job satisfaction. (18.9) You are working just to be promoted for 82 (36.1) 59 (26.0) 36 32 (14.1) 18 (7.9) higher position in order to receive better (15.9) salary. Appraisal system for promotion is transparent 34 (15.0) 44 9 (9.5) 47 78 (34.5) 23 (10.2) and fair. (20.8) 4.3.5. Assessment on motivation Table 5 presents the assessment on the motivation of nurses at the GARH. Overall, 88 (38.7%) of the respondents disagreed hospital management acknowledges their role in the healthcare delivery periodically. Additionally, close to half 103 (45.7%) of the respondents 46 University of Ghana http://ugspace.ug.edu.gh disagreed they get praised for work well done from time to time. Similarly close to half 91 (40.7%) of the respondents disagreed they have firm assurance of job security from the hospital. Moreover, majority 136 (61.1%) of the respondents disagreed the working condition at the hospital motivates them to work to the best of their ability. Likewise, more than half 118 (52.2%) disagreed there is recognition for work accomplishment at the hospital. 4.3.6. Assessment on remuneration Assessment of remuneration is presented in table 5 below. Overall, majority 154 (63.2%) of the respondents disagreed their pay level compared to their work is reasonable. Additionally, close to half 97 (42.4%) disagreed further studies in their field attract salary increase and close to half 108 (47.8%) disagreed they are paid for additional duties. Similarly, most 159 (69.55) disagreed the allowance package they receive is reasonable compared with professionals with similar qualification. Likewise more than half 141 (62.1%) disagreed their employment package is reasonable. Further most 149 (65.4%) disagreed end of service package is adequate and motivates them. Table 4.3.6: Institutional factors: Assessment on motivation and remuneration Assessment on Motivation: Strongly Disagreed Neutral Agreed Strongly Disagree Agreed d Hospital management acknowledges the 41 (18.0) 47 (20.6) 51 80 (35.1) 9 (4.0) role of nurses in health care delivery (22.4) periodically. Nurses from time to time get praised for 50 (22.1) 53 (23.6) 50 63 (28.0) 9 (4.0) work well done. (22.2) I have a firm assurance of job security from 34 (15.2) 57 (25,5) 48 65 (29.0) 20 (8.9) the hospital (21.4) I get motivated from the extent to which I 49 (21.4) 56 (24.6) 50 63 (27.6) 10 (4.4) have adequate training for what I do. (21.9) I receive support and guidance from my 24 (10.6) 50 (22.0) 48 96 (42.3) 9 (4.0) colleagues, supervisor and management as a (21.2) 47 University of Ghana http://ugspace.ug.edu.gh motivation. I get motivated in getting solutions to a 29 (12.8) 55 (24.3) 54 73 (32.3) 15 (6.6) challenging health care delivery. (23.9) Working conditions for nurses at the 74 (32.7) 62 (27.4) 35 44 (19.5) 11 (4.9) Hospital motivate me to work to the best of (15.5) my abilities. There is recognition for work 56 (24.8) 62 (27.4) 53 47 (20.8) 8 (3.5) accomplishment at the Hospital. (23.5) Assessment on Remuneration: Your pay level compared to your work is 111 43 (18.8) 38 21 (9.2) 16 (7.0) reasonable. (48.4) (16.6) Further studies in your field attract salary 62 (27.1) 35 (15.3) 39 69 (30.1) 24 (10.5) increase. (17.0) You are paid for additional duties. 76 (33.6) 32 (14.2) 37 55 (24.3) 26 (11.5) (16.4) Allowance package is reasonable compared 130 29 (12.7) 26 29 (12.7) 15 (6.6) with professions with similar qualification. (56.8) (11.4) My employment welfare package is 98 (43.2) 43 (18.9) 42 25 (11.0) 19 (8.4) reasonable. (18.5) End of service package is adequate and 98 (43.0) 51 (22.4) 39 35 (15.4) 5 (2.2) motivates contemporary nursing. (17.1) 4.4.1. Relationship between nurses’ job satisfaction and socio-demographic characteristics Table 4.4. presents the relationship between nurses‟ job satisfaction and the socio demographic characteristics. Overall, both the simple and the multiple linear regression model show statistically significant (P < 0.001) relationship between job satisfaction and the socio demographic characteristics. The unadjusted analysis show low job satisfaction across both sexes although females seemed to have high job satisfaction compared to their male counterparts. This was not statistically significant (unadjusted k = 2.84; 95 % CI = [-0.002, 0.39]; P > 0.001). There was a statistically significant (unadjusted k = 3.10; 95 % CI = [3.01, 3.20]; P < 0.001) association between the age of respondents and job satisfaction. 48 University of Ghana http://ugspace.ug.edu.gh Respondents in the age group (18-30) years have higher level of satisfaction compared to age groups (31-40) years and (41-50) years (P < 0.05). Additionally there was low but significant relationship between the respondents who were single compared to those who were married (unadjusted k = -0.15; 95 % CI = [-0.30, -0.004]; P = 0.044) as well as the divorced and or the widowed (unadjusted k = -0.70; 95 % CI = [- 1.01, -0.39]; P < 0.001). Job satisfaction decreases with increasing years of experience (Table 7A). Currently apart from respondents who had (1-5) years and (6-10) years working experience, there was low job satisfaction among respondents who had more than 10 years of working experience. This was statistically significant (Unadjusted k = 3.13; 95 % CI = [3.02, 3.23]; P < 0.001). Similar trend was observed for the relationship between respondents‟ job satisfaction and years of practice at the GARH. Additionally, category of nurses or rank of nurses influence job satisfaction; nursing/midwifery officer, senior staff nurse/midwife, senior staff nursing / midwifery officer and principal nursing / midwifery officer were 25%, 49%, 30% and 41% less satisfied with their jobs respectively compared to the enrolled nurses (Table 4.4.1). These were statistically significant (P < 0.001). Similarly respondents who earn 2,100 – 3, 000 GHS were 24% less satisfied compared to those who earn 1000 – 2000 GHS. This was statistically significant (P < 0.001). Low job satisfaction (adjusted k = 2.99; 95 % CI = [2.73, 3.26]; P < 0.001) was observed in the adjusted multiple linear regression model. After adjusting for the confounding effect of sex, age, educational level, years of work and years of practice at the GARH, position, hours of work, and salary, job satisfaction was observed to decrease across marital status (from singles to married to divorced/widowed) as well as how heavy the ward was (slightly heavy