‘Your health our concern, our health whose concern?’: perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana
Identifieur interne : 000433 ( Pmc/Corpus ); précédent : 000432; suivant : 000434‘Your health our concern, our health whose concern?’: perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana
Auteurs : Matilda Aberese-Ako ; Han Van Dijk ; Trudie Gerrits ; Daniel Kojo Arhinful ; Irene Akua AgyepongSource :
- Health Policy and Planning [ 0268-1080 ] ; 2014.
Abstract
Taking a perspective of frontline health workers as internal clients within health systems, this study explored how perceived injustice in policy and organizational matters influence frontline health worker motivation and the consequent effect on workers’ attitudes and performance in delivering maternal and neonatal health care in public hospitals. It consisted of an ethnographic study in two public hospitals in Southern Ghana. Participant observation, conversation and in-depth interviews were conducted over a 16-month period. Ethical approval and consent were obtained from relevant persons and authorities. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. Findings showed that most workers perceived injustice in distributive, procedural and interactional dimensions at various levels in the health system. At the national policy level this included poor conditions of service. At the hospital level, it included perceived inequity in distribution of incentives, lack of protection and respect for workers. These influenced frontline worker motivation negatively and sometimes led to poor response to client needs. However, intrinsically motivated workers overcame these challenges and responded positively to clients’ health care needs. It is important to recognize and conceptualize frontline workers in health systems as internal clients of the facilities and organizations within which they work. Their quality needs must be adequately met if they are to be highly motivated and supported to provide quality and responsive care to their clients. Meeting these quality needs of internal clients and creating a sense of fairness in governance arrangements between frontline workers, facilities and health system managers is crucial. Consequently, intervention measures such as creating more open door policies, involving frontline workers in decision making, recognizing their needs and challenges and working together to address them are critical.
Url:
DOI: 10.1093/heapol/czu068
PubMed: 25274637
PubMed Central: 4202923
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PMC:4202923Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">‘Your health our concern, our health whose concern?’:
perceptions of injustice in organizational relationships and processes and
frontline health worker motivation in Ghana</title><author><name sortKey="Aberese Ako, Matilda" sort="Aberese Ako, Matilda" uniqKey="Aberese Ako M" first="Matilda" last="Aberese-Ako">Matilda Aberese-Ako</name><affiliation><nlm:aff id="czu068-AFF1">Ghana Health Service, Navrongo Health Research Centre, P.O. Box 433, Bolgatanga, UER, Ghana,</nlm:aff></affiliation><affiliation><nlm:aff id="czu068-AFF1">Sociology and Anthropology of Development Group, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The Netherlands,</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Van Dijk, Han" sort="Van Dijk, Han" uniqKey="Van Dijk H" first="Han" last="Van Dijk">Han Van Dijk</name><affiliation><nlm:aff id="czu068-AFF1">Sociology and Anthropology of Development Group, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The Netherlands,</nlm:aff></affiliation></author><author><name sortKey="Gerrits, Trudie" sort="Gerrits, Trudie" uniqKey="Gerrits T" first="Trudie" last="Gerrits">Trudie Gerrits</name><affiliation><nlm:aff id="czu068-AFF1">Graduate School of Social Sciences, Kloveniersburgwal 48 1012 CX Amsterdam, University of Amsterdam, The Netherlands,</nlm:aff></affiliation></author><author><name sortKey="Arhinful, Daniel Kojo" sort="Arhinful, Daniel Kojo" uniqKey="Arhinful D" first="Daniel Kojo" last="Arhinful">Daniel Kojo Arhinful</name><affiliation><nlm:aff wicri:cut=" and" id="czu068-AFF1">Noguchi Memorial Institute for Medical Research, NMIMR, University of Ghana, P.O. Box LG 581 Legon</nlm:aff></affiliation></author><author><name sortKey="Agyepong, Irene Akua" sort="Agyepong, Irene Akua" uniqKey="Agyepong I" first="Irene Akua" last="Agyepong">Irene Akua Agyepong</name><affiliation><nlm:aff id="czu068-AFF1">School of Public Health, University of Ghana, P.O. Box LG 13 Legon</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25274637</idno><idno type="pmc">4202923</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202923</idno><idno type="RBID">PMC:4202923</idno><idno type="doi">10.1093/heapol/czu068</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000433</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000433</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">‘Your health our concern, our health whose concern?’:
perceptions of injustice in organizational relationships and processes and
frontline health worker motivation in Ghana</title><author><name sortKey="Aberese Ako, Matilda" sort="Aberese Ako, Matilda" uniqKey="Aberese Ako M" first="Matilda" last="Aberese-Ako">Matilda Aberese-Ako</name><affiliation><nlm:aff id="czu068-AFF1">Ghana Health Service, Navrongo Health Research Centre, P.O. Box 433, Bolgatanga, UER, Ghana,</nlm:aff></affiliation><affiliation><nlm:aff id="czu068-AFF1">Sociology and Anthropology of Development Group, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The Netherlands,</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Van Dijk, Han" sort="Van Dijk, Han" uniqKey="Van Dijk H" first="Han" last="Van Dijk">Han Van Dijk</name><affiliation><nlm:aff id="czu068-AFF1">Sociology and Anthropology of Development Group, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The Netherlands,</nlm:aff></affiliation></author><author><name sortKey="Gerrits, Trudie" sort="Gerrits, Trudie" uniqKey="Gerrits T" first="Trudie" last="Gerrits">Trudie Gerrits</name><affiliation><nlm:aff id="czu068-AFF1">Graduate School of Social Sciences, Kloveniersburgwal 48 1012 CX Amsterdam, University of Amsterdam, The Netherlands,</nlm:aff></affiliation></author><author><name sortKey="Arhinful, Daniel Kojo" sort="Arhinful, Daniel Kojo" uniqKey="Arhinful D" first="Daniel Kojo" last="Arhinful">Daniel Kojo Arhinful</name><affiliation><nlm:aff wicri:cut=" and" id="czu068-AFF1">Noguchi Memorial Institute for Medical Research, NMIMR, University of Ghana, P.O. Box LG 581 Legon</nlm:aff></affiliation></author><author><name sortKey="Agyepong, Irene Akua" sort="Agyepong, Irene Akua" uniqKey="Agyepong I" first="Irene Akua" last="Agyepong">Irene Akua Agyepong</name><affiliation><nlm:aff id="czu068-AFF1">School of Public Health, University of Ghana, P.O. Box LG 13 Legon</nlm:aff></affiliation></author></analytic><series><title level="j">Health Policy and Planning</title><idno type="ISSN">0268-1080</idno><idno type="eISSN">1460-2237</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Taking a perspective of frontline health workers as internal clients within
health systems, this study explored how perceived injustice in policy and
organizational matters influence frontline health worker motivation and the
consequent effect on workers’ attitudes and performance in delivering
maternal and neonatal health care in public hospitals. It consisted of an
ethnographic study in two public hospitals in Southern Ghana. Participant
observation, conversation and in-depth interviews were conducted over a 16-month
period. Ethical approval and consent were obtained from relevant persons and
authorities. Qualitative analysis software Nvivo 8 was used for coding and
analysis of data. Main themes identified in the analysis form the basis for
interpreting and reporting study findings. Findings showed that most workers
perceived injustice in distributive, procedural and interactional dimensions at
various levels in the health system. At the national policy level this included
poor conditions of service. At the hospital level, it included perceived
inequity in distribution of incentives, lack of protection and respect for
workers. These influenced frontline worker motivation negatively and sometimes
led to poor response to client needs. However, intrinsically motivated workers
overcame these challenges and responded positively to clients’ health care
needs. It is important to recognize and conceptualize frontline workers in
health systems as internal clients of the facilities and organizations within
which they work. Their quality needs must be adequately met if they are to be
highly motivated and supported to provide quality and responsive care to their
clients. Meeting these quality needs of internal clients and creating a sense of
fairness in governance arrangements between frontline workers, facilities and
health system managers is crucial. Consequently, intervention measures such as
creating more open door policies, involving frontline workers in decision
making, recognizing their needs and challenges and working together to address
them are critical.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Adzei, Fa" uniqKey="Adzei F">FA Adzei</name></author><author><name sortKey="Atinga, Ra" uniqKey="Atinga R">RA Atinga</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agyepong, I" uniqKey="Agyepong I">I Agyepong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agyepong, I" uniqKey="Agyepong I">I Agyepong</name></author><author><name sortKey="Anafi, P" uniqKey="Anafi P">P Anafi</name></author><author><name sortKey="Ansah, E" uniqKey="Ansah E">E Ansah</name></author><author><name sortKey="Ashon, D" uniqKey="Ashon D">D Ashon</name></author><author><name sortKey="Na Dometey, C" uniqKey="Na Dometey C">C Na-Dometey</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agyepong, I" uniqKey="Agyepong I">I Agyepong</name></author><author><name sortKey="Sollecito, W" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Health Policy Plan</journal-id><journal-id journal-id-type="iso-abbrev">Health Policy Plan</journal-id><journal-id journal-id-type="publisher-id">heapol</journal-id><journal-id journal-id-type="hwp">heapol</journal-id><journal-title-group><journal-title>Health Policy and Planning</journal-title></journal-title-group><issn pub-type="ppub">0268-1080</issn><issn pub-type="epub">1460-2237</issn><publisher><publisher-name>Oxford University Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25274637</article-id><article-id pub-id-type="pmc">4202923</article-id><article-id pub-id-type="doi">10.1093/heapol/czu068</article-id><article-id pub-id-type="publisher-id">czu068</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>‘Your health our concern, our health whose concern?’:
perceptions of injustice in organizational relationships and processes and
frontline health worker motivation in Ghana</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Aberese-Ako</surname><given-names>Matilda</given-names></name><xref ref-type="aff" rid="czu068-AFF1"><sup>1</sup></xref><xref ref-type="aff" rid="czu068-AFF1"><sup>2</sup></xref><xref ref-type="aff" rid="czu068-AFF1">*</xref></contrib><contrib contrib-type="author"><name><surname>van Dijk</surname><given-names>Han</given-names></name><xref ref-type="aff" rid="czu068-AFF1"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Gerrits</surname><given-names>Trudie</given-names></name><xref ref-type="aff" rid="czu068-AFF1"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Arhinful</surname><given-names>Daniel Kojo</given-names></name><xref ref-type="aff" rid="czu068-AFF1"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Agyepong</surname><given-names>Irene Akua</given-names></name><xref ref-type="aff" rid="czu068-AFF1"><sup>5</sup></xref></contrib><aff id="czu068-AFF1"><sup>1</sup>Ghana Health Service, Navrongo Health Research Centre, P.O. Box 433, Bolgatanga, UER, Ghana,<sup>2</sup>Sociology and Anthropology of Development Group, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The Netherlands,<sup>3</sup>Graduate School of Social Sciences, Kloveniersburgwal 48 1012 CX Amsterdam, University of Amsterdam, The Netherlands,<sup>4</sup>Noguchi Memorial Institute for Medical Research, NMIMR, University of Ghana, P.O. Box LG 581 Legon and<sup>5</sup>School of Public Health, University of Ghana, P.O. Box LG 13 Legon</aff></contrib-group><author-notes><corresp id="czu068-COR1">*Corresponding author. P.O. Box 433, Bolgatanga, Upper
East Region, Ghana or Sociology and Anthropology of Development Group,
Wageningen University, P.O. Box 8130, 6700 EW, Hollandseweg 1, Wageningen, The
Netherlands. E-mail: <email>matilda.aberese-ako@wur.nl</email> or
<email>maberese@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><month>9</month><year>2014</year></pub-date><pub-date pub-type="epub"><day>11</day><month>9</month><year>2014</year></pub-date><pub-date pub-type="pmc-release"><day>11</day><month>9</month><year>2014</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on the
<volume>29</volume><issue>Suppl 2</issue><issue-title>Science and Practice of People-Centred Health Systems</issue-title><fpage>ii15</fpage><lpage>ii28</lpage><history><date date-type="accepted"><day>25</day><month>6</month><year>2014</year></date></history><permissions><copyright-statement>Published by Oxford University Press in association with The
London School of Hygiene and Tropical Medicine © The Author 2014; all
rights reserved.</copyright-statement><copyright-year>2014</copyright-year><license xlink:href="http://creativecommons.org/licenses/by/4.0/" license-type="creative-commons"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits
unrestricted reuse, distribution, and reproduction in any medium, provided
the original work is properly cited.</license-p></license></permissions><abstract><p>Taking a perspective of frontline health workers as internal clients within
health systems, this study explored how perceived injustice in policy and
organizational matters influence frontline health worker motivation and the
consequent effect on workers’ attitudes and performance in delivering
maternal and neonatal health care in public hospitals. It consisted of an
ethnographic study in two public hospitals in Southern Ghana. Participant
observation, conversation and in-depth interviews were conducted over a 16-month
period. Ethical approval and consent were obtained from relevant persons and
authorities. Qualitative analysis software Nvivo 8 was used for coding and
analysis of data. Main themes identified in the analysis form the basis for
interpreting and reporting study findings. Findings showed that most workers
perceived injustice in distributive, procedural and interactional dimensions at
various levels in the health system. At the national policy level this included
poor conditions of service. At the hospital level, it included perceived
inequity in distribution of incentives, lack of protection and respect for
workers. These influenced frontline worker motivation negatively and sometimes
led to poor response to client needs. However, intrinsically motivated workers
overcame these challenges and responded positively to clients’ health care
needs. It is important to recognize and conceptualize frontline workers in
health systems as internal clients of the facilities and organizations within
which they work. Their quality needs must be adequately met if they are to be
highly motivated and supported to provide quality and responsive care to their
clients. Meeting these quality needs of internal clients and creating a sense of
fairness in governance arrangements between frontline workers, facilities and
health system managers is crucial. Consequently, intervention measures such as
creating more open door policies, involving frontline workers in decision
making, recognizing their needs and challenges and working together to address
them are critical.</p></abstract><kwd-group kwd-group-type="keywords"><kwd>Attitude</kwd><kwd>frontline health workers</kwd><kwd>Ghana</kwd><kwd>justice</kwd><kwd>motivation</kwd><kwd>people-centred health systems</kwd></kwd-group><counts><page-count count="14"></page-count></counts></article-meta></front><body><p><boxed-text id="czu068-BOX1" position="float"><caption><title>KEY MESSAGES</title></caption><p><list list-type="bullet"><list-item><p>Frontline health workers perceive that they do not receive
‘people-centered care’ from their employers, despite
being asked to provide ‘people-centered care’ to the
clients that come to health facilities. This considerably weakens
the credibility of the message they are being given to treat their
clients in a responsive manner.</p></list-item><list-item><p>They perceive procedural, distributive and interactional injustice at
policy and organizational levels, which have a strong influence on
worker motivation and response to client health care needs.</p></list-item><list-item><p>Health workers’ quality needs must be adequately met if they
are to be adequately motivated and supported to provide high quality
and responsive care to clients they interact with on a daily
basis.</p></list-item><list-item><p>An important dimension to meeting these quality needs of frontline
workers is real and perceived justice in governance arrangements
that puts a human face to interactions between
frontline workers and their facility and health system managers such
as creating more open door policies, involving frontline workers in
decision making, recognizing their needs and challenges and working
together to address them is crucial.</p></list-item></list></p></boxed-text></p><sec sec-type="intro"><title>Introduction</title><p>Policy makers and other agents responsible for reforming African health institutions
and systems have often blamed health workers for a poorly responsive health system,
suggesting that health workers interact and communicate poorly with clients (<xref rid="czu068-B4" ref-type="bibr">Agyepong <italic>et al.</italic> 2001</xref>;
<xref rid="czu068-B54" ref-type="bibr">Ministry of Health 2001</xref>; <xref rid="czu068-B9" ref-type="bibr">Andersen 2004</xref>; <xref rid="czu068-B55" ref-type="bibr">Ministry of Health 2007</xref>). Interventions to improve
quality and responsiveness in healthcare have centred on professionals and frontline
workers without recourse to a total system reform (<xref rid="czu068-B4" ref-type="bibr">Agyepong <italic>et al.</italic> 2001</xref>). Yet, low health
worker motivation and discontent continue to be cited as major causes of poor
healthcare quality and outcomes in Sub Saharan Africa including Ghana (<xref rid="czu068-B3" ref-type="bibr">Agyepong <italic>et al.</italic> 2004</xref>;
<xref rid="czu068-B49" ref-type="bibr">Luoma 2006</xref>; <xref rid="czu068-B17" ref-type="bibr">Chandler <italic>et al.</italic> 2009</xref>; <xref rid="czu068-B1" ref-type="bibr">Adzei and Atinga 2012</xref>; <xref rid="czu068-B5" ref-type="bibr">Agyepong <italic>et al.</italic> 2012</xref>;
<xref rid="czu068-B6" ref-type="bibr">Alhassan <italic>et al.</italic>2013</xref>; <xref rid="czu068-B27" ref-type="bibr">Faye <italic>et al.</italic>2013</xref>). Worker motivation can be defined as the degree of willingness of
the worker to maintain efforts towards achieving organizational goals (<xref rid="czu068-B39" ref-type="bibr">Kanfer 1999</xref>; <xref rid="czu068-B30" ref-type="bibr">Franco <italic>et al.</italic> 2002</xref>). Extrinsic
motivation factors including contingent rewards such as salary, policy reforms and
organizational factors and intrinsic motivation factors that embody the
individual’s desire to perform the task for its own sake, which is self
generated and non-financial such as interpersonal factors have been cited as
influencing worker motivation in Africa including Ghana (<xref rid="czu068-B3" ref-type="bibr">Agyepong <italic>et al.</italic> 2004</xref>; <xref rid="czu068-B9" ref-type="bibr">Andersen 2004</xref>; <xref rid="czu068-B18" ref-type="bibr">Chen <italic>et al.</italic> 2004</xref>; <xref rid="czu068-B60" ref-type="bibr">Rowe <italic>et al.</italic> 2005</xref>; <xref rid="czu068-B10" ref-type="bibr">Ansong-Tornui <italic>et al.</italic> 2007</xref>; <xref rid="czu068-B14" ref-type="bibr">Bosu <italic>et al.</italic> 2007</xref>; <xref rid="czu068-B68" ref-type="bibr">Witter <italic>et al.</italic> 2007</xref>;
<xref rid="czu068-B67" ref-type="bibr">Willis-Shattuck <italic>et al.</italic>2008</xref>; <xref rid="czu068-B52" ref-type="bibr">Mbindyo <italic>et
al.</italic> 2009</xref>; <xref rid="czu068-B62" ref-type="bibr">Songstad
<italic>et al.</italic> 2011</xref>; <xref rid="czu068-B58" ref-type="bibr">Prytherch <italic>et al.</italic> 2012</xref>; <xref rid="czu068-B56" ref-type="bibr">Mutale <italic>et al.</italic> 2013</xref>). Thus, worker
motivation is an important indicator of the quality and responsiveness of an
organization towards its frontline health workers.</p><p>Continuous quality improvement (CQI) is a management philosophy as well as approach.
It is a philosophy in that it has underlying beliefs, ways of thinking, concepts and
attitudes about quality improvement. From a CQI philosophical perspective, quality
is the product of a chain in which each person is a customer (client) of the people
in the process preceding theirs (<xref rid="czu068-B53" ref-type="bibr">McLaughlin
and Kaluzny 1994</xref>; <xref rid="czu068-B4" ref-type="bibr">Agyepong
<italic>et al.</italic> 2001</xref>, <xref rid="czu068-B3" ref-type="bibr">2004</xref>). The external users of the services of a particular organization
e.g. the mother who brings her child for an immunization or the woman who comes to
deliver at a health facility, who in the health system are called clients or
patients are the last in the chain. The quality and responsiveness of the service
they receive will be influenced by the quality and responsiveness of the whole
customer chain, which starts at the top of the organization and ends with them. In
this conceptualization, the workers in an organization are seen as internal
customers or clients and the clients at the end of the chain are the external
customers or clients. For example, if the administration office has delayed a
nurse’s request for better conditions of service or supplies, she may become
irritated and frustrated and the chances that she will have a negative attitude
towards her work increases, which in turn will influence her response to her clients
(external customers of the organization). The CQI philosophical concept of internal
and external customers of an organization may be a more inclusive concept to use in
thinking through how to make health systems people centred. The nurse in our
illustrative example has not received ‘people-centred care’ from her
organization, which may negatively affect her ability to deliver
‘people-centred care’ to the clients (external customers) who have come
to her. People-centred care has been defined as: <disp-quote content-type="extract"><p> “….care that is focused and organized around people,
rather than diseases. Within a people-centred approach, disease prevention
and management are seen as important, but are not sufficient to address the
needs and expectations of people and communities. The central focus is on
the person in the context of his or her family, community, and culture
(<xref rid="czu068-B66" ref-type="bibr">WHO
2011</xref>).”</p></disp-quote> Drawing upon the CQI philosophy related to
internal and external customers, if quality is the end result of a linked chain from
internal through to external customers; then for an organization to function well
and provide quality care to its clients, it has to take care of the quality needs of
its workers or internal customers. This study sought to explore frontline health
worker experiences and perceptions of justice in national and organizational
policies, processes and procedures relevant to their work; and how these issues
influence their motivation and responsiveness to clients in the provision of
maternal and neonatal health care. The study answered the questions: How do
frontline health workers perceive justice (fairness) in the support they receive
from the organization they work for and how does that influence their motivation to
respond to their clients’ health care needs? To explore the various dimensions
of worker experiences organizational justice theory has been employed.</p><p>Organizational justice theory is one of the critical theories in studying worker
motivation (<xref rid="czu068-B46" ref-type="bibr">Latham and Pinder 2005</xref>;
<xref rid="czu068-B69" ref-type="bibr">Zapata-Phelan <italic>et al.</italic>2009</xref>; <xref rid="czu068-B62" ref-type="bibr">Songstad <italic>et
al.</italic> 2011</xref>). Justice and fairness are concepts with similar
meanings and in this paper will be used interchangeably. Both concepts have to do
with impartiality, reasonableness, justice and equity (<xref rid="czu068-B2" ref-type="bibr">Agyepong 2012</xref>). Organizational justice is used to
pinpoint the individual’s belief that the distribution of outcomes, or
procedures for distributing outcomes such as pay and other opportunities are fair
and appropriate when they satisfy certain criteria (<xref rid="czu068-B47" ref-type="bibr">Leventhal 1976</xref>; <xref rid="czu068-B13" ref-type="bibr">Bell <italic>et al.</italic> 2006</xref>). The theory is relevant to this study
because perceptions of justice have been known to elicit different behavioural
reactions including positive or negative attitudes in worker response to work
demands and performance within organizations (<xref rid="czu068-B36" ref-type="bibr">Greenberg 1993</xref>; <xref rid="czu068-B41" ref-type="bibr">Konovsky
2000</xref>; <xref rid="czu068-B44" ref-type="bibr">Laschinger 2003</xref>;
<xref rid="czu068-B20" ref-type="bibr">Colquitt <italic>et al.</italic>2006</xref>; <xref rid="czu068-B69" ref-type="bibr">Zapata-Phelan <italic>et
al.</italic> 2009</xref>). When workers perceive injustice they may become
demotivated and repay the organization with negative attitudes, which affects
organizational climate. Where they perceive fairness they are more inclined to be
motivated and repay the organization with positive attitudes including trust and
positive response to organizational and clients’ needs (<xref rid="czu068-B21" ref-type="bibr">Cropanzano <italic>et al.</italic> 2002</xref>).</p><p>We theorized that a frontline health worker’s judgement of fairness in policy
and organizational processes elicits reactions that influence motivation and
response towards work, which affects the worker’s desire to perform tasks that
contributes to the achievement of organizational goals. This makes organizational
justice an appropriate concept for exploring processes that shape health worker
motivation and response to clients’ needs in a hospital context.</p><p>The idea of organizational justice is based on Leventhal’s two-dimensional
distinction of procedural and distributive justice (<xref rid="czu068-B47" ref-type="bibr">Leventhal 1976</xref>) and interactional justice (<xref rid="czu068-B41" ref-type="bibr">Konovsky 2000</xref>; <xref rid="czu068-B19" ref-type="bibr">Colquitt <italic>et al.</italic> 2001</xref>). Procedural
justice is defined as an individual’s belief that allocative procedures or
decision-making processes, which satisfy certain criteria are fair and appropriate
(<xref rid="czu068-B47" ref-type="bibr">Leventhal 1976</xref>; <xref rid="czu068-B21" ref-type="bibr">Cropanzano <italic>et al.</italic>2002</xref>). Distributive justice is perceived as the individual’s belief
that it is fair and appropriate when outcomes or rewards such as salary, punishments
or resources are distributed in accordance with certain criteria (<xref rid="czu068-B47" ref-type="bibr">Leventhal 1976</xref>; <xref rid="czu068-B19" ref-type="bibr">Colquitt <italic>et al.</italic> 2001</xref>; <xref rid="czu068-B63" ref-type="bibr">Stinglhamber <italic>et al.</italic>2006</xref>; <xref rid="czu068-B21" ref-type="bibr">Cropanzano <italic>et
al.</italic> 2002</xref>). Interactional justice has been defined as the
quality of interaction between individuals (<xref rid="czu068-B21" ref-type="bibr">Cropanzano <italic>et al.</italic> 2002</xref>; <xref rid="czu068-B63" ref-type="bibr">Stinglhamber <italic>et al.</italic> 2006</xref>).
Interactional justice contains two aspects, informational and interpersonal justice.
Informational justice is defined as the extent to which individuals are provided
with information or rationale for how decisions are made (<xref rid="czu068-B36" ref-type="bibr">Greenberg 1993</xref>; <xref rid="czu068-B44" ref-type="bibr">Laschinger 2003</xref>; <xref rid="czu068-B7" ref-type="bibr">Almost
2006</xref>). Interpersonal justice is defined as the extent to which
individuals are treated with respect and dignity (<xref rid="czu068-B36" ref-type="bibr">Greenberg 1993</xref>; <xref rid="czu068-B44" ref-type="bibr">Laschinger 2003</xref>; <xref rid="czu068-B7" ref-type="bibr">Almost
2006</xref>).</p><p>All three dimensions of justice distributive, procedural and interactional justice
will be used in this study to explore workers’ perceptions of justice in
policy and organizational processes within the hospital context, as they were
evident in worker narratives. Although distributive justice focuses on the final
outcome, procedural justice deals with the processes involved in arriving at the
final outcome (<xref rid="czu068-B47" ref-type="bibr">Leventhal 1976</xref>). The
line between the two can be very thin, and in our findings some of the issues
presented had both procedural and distributive justice complexly interrelated, so
the two dimensions of justice will be discussed concurrently.</p></sec><sec sec-type="methods"><title>Methods</title><p>Health worker motivation has been widely studied using a variety of qualitative
(<xref rid="czu068-B22" ref-type="bibr">Dieleman <italic>et al.</italic>2003</xref>; <xref rid="czu068-B23" ref-type="bibr">Dieleman <italic>et
al.</italic> 2006</xref>; <xref rid="czu068-B15" ref-type="bibr">Bradley and
McAuliffe 2009</xref>) and quantitative (<xref rid="czu068-B31" ref-type="bibr">Franco <italic>et al.</italic> 2004</xref>; <xref rid="czu068-B59" ref-type="bibr">Purohit and Bandyopadhyay 2014</xref>) methods. To reflect the
complex nature of factors influencing health worker motivation in Africa including
Ghana (<xref rid="czu068-B38" ref-type="bibr">Hongoro and Normand 2006</xref>), an
ethnographic study was conducted in two public hospitals in Southern Ghana.
Ethnographic studies provide ‘thick description’ (<xref rid="czu068-B34" ref-type="bibr">Geertz 1973</xref>) and rich details of social phenomena.
Additionally, they provide voice to those such as frontline workers whose
experiences receive little attention (<xref rid="czu068-B26" ref-type="bibr">Fahie
2014</xref>). This method requires long and active periods in the site of study
to learn, experience and represent the lives of subjects in their natural setting
(<xref rid="czu068-B64" ref-type="bibr">Van der Geest and Sarkodie 1998</xref>;
<xref rid="czu068-B25" ref-type="bibr">Emerson <italic>et al.</italic>2005</xref>). Consequently, M.A. referred to as ‘the researcher’
worked as a student researcher in the two hospitals over a 16-month period as part
of her PhD thesis research. She employed ethnographic methods including participant
observation, conversation and in-depth interviews to collect data among health
workers in the hospitals. As an active participant in the process of health care
provision, the researcher observed how motivation and demotivation is produced
through worker interaction with their environment.</p><p>For purposes of anonymity, the hospitals are referred to as Facility A and Facility B
and pseudonyms are used for all names used in this article. Facility A serves a
metropolitan area with a population of about half a million. It has specialist
units, services, as well as workers including obstetrician gynaecologists,
anaesthetists and paediatricians. It provides comprehensive inpatient care with a
bed complement of 294. It has a theatre that permits major surgical operations and
the full range of emergency obstetric services in addition to routine delivery
services. Facility B serves a peri-urban population of about 200 000 inhabitants. It
has a bed capacity of 20 and provides only basic maternity services. It had no
theatre for major surgical operations during the period of study, but efforts were
being made to set up one. The facility refers complicated obstetric and
gynaecological cases needing specialized services to better-equipped facilities
outside the district. Its doctors are general practitioners.</p><p>Facility A was selected to help gain insight into the study questions in the context
of a big specialist hospital. Facility B was chosen to help understand the same
issues in a smaller non-specialist hospital. Data were collected in two phases. M.A.
collected data in the maternity and new-born units of Facility A from January to
September 2012 and in the maternity department of Facility B from October to
December 2012. In the second phase, she collected data in Facility B in July and
August 2013 and in Facility A in October and November 2013. <xref ref-type="table" rid="czu068-T1">Table 1</xref> gives a breakdown of categories of workers and
the methods used to obtain data. Data were collected on task agreement,
relationships between professional groups and management, challenges and benefits in
health care provision, trust relations and motivation. Attitudes and workers’
response to clients’ needs were observed by the researcher as well as
crosschecked with health care providers. <table-wrap id="czu068-T1" position="float"><label>Table
1</label><caption><p>Categories of workers in Facilities A and B who were
included in the study and methods used in collecting data</p></caption><table frame="hsides" rules="groups"><thead align="left"><tr><th rowspan="2" colspan="1">Category of workers</th><th align="center" colspan="2" rowspan="1">Data collection methods</th></tr><tr><th rowspan="1" colspan="1">Conversation</th><th rowspan="1" colspan="1">Interviews</th></tr></thead><tbody align="left"><tr><td rowspan="1" colspan="1"><bold>Facility A</bold><xref ref-type="table-fn" rid="czu068-TF1"><bold><sup>a</sup></bold></xref></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Nurses and midwives</td><td rowspan="1" colspan="1">62</td><td rowspan="1" colspan="1">12</td></tr><tr><td rowspan="1" colspan="1"> House officers</td><td rowspan="1" colspan="1">5</td><td rowspan="1" colspan="1">2</td></tr><tr><td rowspan="1" colspan="1"> Senior doctors</td><td rowspan="1" colspan="1">11</td><td rowspan="1" colspan="1">4</td></tr><tr><td rowspan="1" colspan="1"> Anaesthetists</td><td rowspan="1" colspan="1">5</td><td rowspan="1" colspan="1">3</td></tr><tr><td rowspan="1" colspan="1"> Ward aids</td><td rowspan="1" colspan="1">2</td><td rowspan="1" colspan="1">2</td></tr><tr><td rowspan="1" colspan="1"> Orderlies</td><td rowspan="1" colspan="1">6</td><td rowspan="1" colspan="1">6</td></tr><tr><td rowspan="1" colspan="1"> Doctors who left Facility A</td><td rowspan="1" colspan="1">—</td><td rowspan="1" colspan="1">2</td></tr><tr><td rowspan="1" colspan="1"> Laboratory officials</td><td rowspan="1" colspan="1">—</td><td rowspan="1" colspan="1">2</td></tr><tr><td rowspan="1" colspan="1"> Departmental supervisors</td><td rowspan="1" colspan="1">9</td><td rowspan="1" colspan="1">1</td></tr><tr><td rowspan="1" colspan="1"> Facility management workers</td><td rowspan="1" colspan="1">3</td><td rowspan="1" colspan="1">4</td></tr><tr><td rowspan="1" colspan="1"><bold>Facility B</bold><xref ref-type="table-fn" rid="czu068-TF2"><bold><sup>b</sup></bold></xref></td><td colspan="2" rowspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Nurses and midwives</td><td rowspan="1" colspan="1">23</td><td rowspan="1" colspan="1">7</td></tr><tr><td rowspan="1" colspan="1"> Nurse who left the facility</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1">1</td></tr><tr><td rowspan="1" colspan="1"> Doctor</td><td rowspan="1" colspan="1">1</td><td rowspan="1" colspan="1">1</td></tr><tr><td rowspan="1" colspan="1"> Ward aids</td><td rowspan="1" colspan="1">4</td><td rowspan="1" colspan="1">—</td></tr><tr><td rowspan="1" colspan="1"> Departmental supervisors</td><td rowspan="1" colspan="1">3</td><td rowspan="1" colspan="1">4</td></tr><tr><td rowspan="1" colspan="1"> Facility management workers</td><td rowspan="1" colspan="1">2</td><td rowspan="1" colspan="1">4</td></tr></tbody></table><table-wrap-foot><fn id="czu068-TF1"><p><sup>a</sup>In Facility A observation was carried out
in the antenatal and postnatal clinics, labour, lying in and the
gynaecological wards and the maternity theatre. Additionally, the
ethnographer participated in meetings, doctors’ ward rounds,
training and workshops for workers.</p></fn><fn id="czu068-TF2"><p><sup>b</sup>In Facility B observations were done in
the antenatal and postnatal clinics, the labour ward and the
hospital pharmacy. Also, the ethnographer participated in district
annual performance review and a party for five retirees.</p></fn></table-wrap-foot></table-wrap></p><p>Notes from observation of events, participation in workshops among others and
conversations were jotted down in field note books. The notes were reconstructed and
expanded at the end of each field visit in line with standard ethnographic studies
(<xref rid="czu068-B25" ref-type="bibr">Emerson <italic>et al.</italic>2005</xref>). Interviews were tape recorded and transcribed verbatim by a
neutral researcher. The aim of employing a neutral researcher was to preserve
interviewees’ original expressions and to enhance validity of the study.
Observation notes, conversations and transcribed interviews were typed and
transferred to qualitative analysis software Nvivo (version 8), which was used to
generate a coding list on common themes that arose from the data. Subsequently, the
data were systematically analysed to identify patterns, differences and
contradictions. Secondary data including institutional reports, policy guidelines
and circulars were used to support and crosscheck the findings.</p><p>Main themes identified were related to distributive, procedural and interactional
justices at local hospital management and the wider health sector decision-making
levels. These three dimensions of justice form the basis for interpreting and
reporting on study findings at the two levels. Additionally, intrinsic motivating
factors were found and they are also discussed. While different categories of
frontline workers were studied, the findings focuses on doctors, nurses and
anaesthetists’ experiences, because these three categories of frontline
workers are tasked with the core responsibility of providing maternal and neonatal
health care.</p></sec><sec><title>Findings</title><p>The researcher participated in a workshop that was organized by the management of
Facility A for selected health workers (administrators, doctors, nurses, paramedics)
at the facility. The objective of the workshop was to improve workers’
knowledge on legal issues concerning the rights of workers and clients. Towards the
close of the workshop workers were given the opportunity to ask questions. The
excerpts below of a question a nurse–administrator asked a facilitator who is
a doctor and also a frontline worker and the response shows in a nutshell perceived
policy and organizational injustice issues encountered by nurses, doctors and
anaesthetists in everyday health care provision in Facility A as indeed was also the
case in Facility B, where subsequent fieldwork was conducted. <disp-quote content-type="extract"><p>“Nurse: We have been talking about how to attend
to clients for two days, what do you have for us, health workers?</p><p>Facilitator: It is shameful that companies pay for their workers who we take
care of. But in health institutions we who take care of them pay our own
medical bills. ‘Your health our concern, our health whose
concern?’ That is why they believe health workers steal things. In
those institutions they reimburse health bills. Why do you think you should
use all the internally generated funds (IGFs) for services and not to take
care of yourselves? You think VALCO and Electricity Company of Ghana use all
their money to buy steel and electricity! They use some to take care of
their workers.”<xref ref-type="fn" rid="czu068-NT1"><sup>1</sup></xref></p></disp-quote> The interaction suggests that
health workers perceive that the values they are being asked to hold for their
clients are not the values they feel are being held for them as people in the health
system by their employers.</p><p>First, the nurse’s question suggests perceived neglect of frontline workers,
who are yearning for attention. Second, the facilitator presents layers of perceived
injustice confronting health workers. He suggests injustice in policy regarding
conditions of service of health workers compared with their colleagues in other
establishments. He also brings out organizational matters including interactional
injustice regarding a common negative perception that health workers are thieves who
steal medical supplies from public hospitals to sell to private hospitals.
Additionally, he brings out issues of distributive injustice on how monies generated
by health workers within their facilities are used. He suggests that the electricity
company that supplies most parts of the country electric power and VALCO company,
which produces aluminium derived from bauxite of world-class quality to meet local
demand and for export, are ‘people centred’, because they use their
companies’ revenue to purchase raw materials for production to meet their
external customers’ electric power needs and equally use part of it to take
care of their internal ‘customers’’ health needs. He juxtaposes
the Ghana Health Service (GHS) logo: ‘Your health our concern’, which
suggests that the health of the external customer is the responsibility of the
health worker with ‘Our health whose concern?’: implying that the health
worker’s health needs are not the responsibility of anyone.</p><p>Thus, health workers who are the custodians of health care of the general public
perceive that they do not receive ‘people-centred’ care. This
interaction fits Ntim’s assertion in his article on economic governance and
social accountability in Ghana: ‘The moment there is a perception of
unfairness—that others are having more than their due, this de facto
precipitates agitation<italic>’</italic> (<xref rid="czu068-B57" ref-type="bibr">Ntim 2013</xref>). This goes to support other findings in this
study that suggest that majority of frontline health workers perceive distributive,
procedural and interactional injustice to be operating at local hospital management
and the wider health sector decision-making levels. By the wider health sector
decision-making level, we are referring to the Ministry of Health as well as its
national directorate; the GHS and the regional-level directorates, which have the
responsibility for making decisions that become authoritative for the lower levels
(districts, hospitals and below). In the rest of this section the findings will
present narratives of frontline workers based on <xref ref-type="fig" rid="czu068-F1">Figure 1</xref> as follows: distributive, procedural and
interactional injustice at hospital management and the wider health sector
decision-making levels. Factors influencing intrinsic motivation of frontline
workers and consequences on workers’ response to clients’ needs will
also be discussed. <fig id="czu068-F1" position="float"><label>Figure<sc>1</sc></label><caption><p>Processes in health worker
motivation.</p></caption><graphic xlink:href="czu068f1p"></graphic></fig></p></sec><sec><title>Perceived procedural and distributive injustice related to local hospital
management</title><p>Frontline workers perceived distributive injustice by hospital management in the
provision of incentives and response to equipment, tools and supplies to work with
and their infrastructure needs, which are discussed below.</p><p>Workers in Facility A said in past times they were given incentives such as a monthly
transport allowance and a Christmas package. However in recent times management had
failed to provide these incentives, which they considered unfair.<xref ref-type="fn" rid="czu068-NT2"><sup>2</sup></xref> They suggested that it had contributed to a
reduction in worker motivation to respond to clients’ needs. In the words of a
frontline worker: <disp-quote content-type="extract"><p> “I think the problems
are coming from here. Last two years when they decided not to motivate us at
Christmas, they thought we will talk, so the director quickly went on
leave….People are not complaining because they are all smart and
finding their way around by doing their own things.”<xref ref-type="fn" rid="czu068-NT3"><sup>3</sup></xref></p></disp-quote>Additionally, interviews and conversations with nurses, anaesthetists and doctors
including some doctors who had left Facility A, suggested that they perceived that
management did not treat doctors posted to the maternity department fairly. So they
were not motivated to stay. One of the doctors who had left the facility stated:
‘I thought ‘I will be given accommodation at Facility A’, but they
denied me. I thought after that ‘they will give me some allowance for
fuel’; no they denied me.’<xref ref-type="fn" rid="czu068-NT4"><sup>4</sup></xref></p><p>In response, a management worker said that the facility stopped providing incentives
to workers because a directive from the director general’s office in 2008
ordered all facilities to stop issuing incentives.<xref ref-type="fn" rid="czu068-NT5"><sup>5</sup></xref> Some frontline workers indicated that they
were aware of the directive. Nevertheless they argued that their output is high,
which enables the hospital to generate a lot of revenue. So, it was only fair that
they should be appreciated for their efforts by being given monetary
incentives.<xref ref-type="fn" rid="czu068-NT6"><sup>6</sup></xref></p><p>On the issue of doctors leaving Facility A, the facility manager responded that the
facility had recently introduced an incentive package specially for doctors in the
maternity department to help maintain the few doctors that were in the
department.<xref ref-type="fn" rid="czu068-NT7"><sup>7</sup></xref></p><p>In Facility B, midwives complained of lack of incentives including the provision of
drinking water, infrequent allocation of Christmas bonuses and stoppage in providing
night cups (coffee, tea and biscuits) for workers on night duty.<xref ref-type="fn" rid="czu068-NT8"><sup>8</sup></xref> In response, two management workers
explained that management in consultation with frontline workers agreed to sacrifice
all incentives to workers and rather use the money to buy essential items, which
were required for a peer review<xref ref-type="fn" rid="czu068-NT9"><sup>9</sup></xref> exercise. They said that all frontline workers agreed to
sacrifice and were happy about it.<xref ref-type="fn" rid="czu068-NT10"><sup>10</sup></xref> Conversations with midwives on night duty, however,
suggested that they were not aware of this arrangement.<xref ref-type="fn" rid="czu068-NT11"><sup>11</sup></xref></p><p>Some workers in Facility A bemoaned deteriorating conditions of the hospital’s
infrastructure resulting in some injuries to workers. For instance during a maternal
audit meeting a senior nurse and a senior doctor narrated how a theatre door fell on
a nurse. No compensation was provided to the nurse afterwards. They suggested that
it was not fair that though their efforts brought in money management did not
provide them with a conducive work environment.<xref ref-type="fn" rid="czu068-NT12"><sup>12</sup></xref> A frontline worker summed the situation up:
<disp-quote content-type="extract"><p>“All that we are asking is every day
we work, but where does the money go? Look at the air conditioners and the
fans on the wards, they are not working! But when you go to their offices
(management workers) you will see that everything works.…Yet, those
of us who do the real work and bring in the money, you come to our offices
and we are crammed and nothing works.”<xref ref-type="fn" rid="czu068-NT13"><sup>13</sup></xref></p></disp-quote> In both
hospitals, frontline workers perceived procedural injustice in their respective
hospitals management response to their equipment and basic medical supplies needs.
Some added that sometimes they were not involved in decisions to acquire supplies
and equipment, for which they are the end users. Also whenever they were involved
their views were not taken into consideration.<xref ref-type="fn" rid="czu068-NT14"><sup>14</sup></xref> They felt that the hospitals delayed in providing them
with basic supplies and sometimes they were given substandard products to work with.
They perceived these acts as unfair to frontline workers who have to improvise on
such occasions to provide health care to clients. They argued that this contributed
to delays in providing services to clients. Some said using substandard products
contributed to the provision of poor quality care to clients. They indicated that
poor response by managers to provide their working essentials was demotivating.<xref ref-type="fn" rid="czu068-NT15"><sup>15</sup></xref></p><p>Management workers on the other hand responded that the seemingly poor response to
supplies and equipment needs was because facilities are required to follow
procurement laws for bulk purchases. Unfortunately, the procurement process takes
some time and that accounts for the delay.<xref ref-type="fn" rid="czu068-NT16"><sup>16</sup></xref> For substandard medicines and other supplies, they
admitted that this was a challenge to management as well. Facilities are by law not
allowed to buy supplies and equipment from the open market if the Central or
Regional Medical stores have some in stock. Yet, sometimes medicines issued to
facilities from the Central medical stores are expired or fake. To support this
assertion, two management members cited an occasion that Facility B returned
quantities of oxytocin,<xref ref-type="fn" rid="czu068-NT17"><sup>17</sup></xref>which the medical stores supplied to the hospital, because they were discovered to
be fake.<xref ref-type="fn" rid="czu068-NT18"><sup>18</sup></xref></p><p>The majority of workers indicated that management’s inability to provide
incentives, the needed medical supplies and failure to maintain safety standards was
demotivating and a sign of management’s lack of appreciation of their work.
Thus they did not trust that management was working in workers’
interests.<xref ref-type="fn" rid="czu068-NT19"><sup>19</sup></xref> This
supports <xref rid="czu068-B1" ref-type="bibr">Adzei and Atinga’s
(2012)</xref> study, which suggests that resources to work with and the quality
of hospital infrastructure are significant determining factors of health worker
motivation and retention in district hospitals in Ghana. Other studies equally
suggest that health workers’ inability to pursue their vocation due to lack of
means and supplies is a demotivator (<xref rid="czu068-B51" ref-type="bibr">Mathauer
and Imhoff 2006</xref>). Also related to this finding but in a contrary
direction procedural justice has been found to lead to increased job satisfaction,
organizational commitment and organizational citizenship behaviour (<xref rid="czu068-B41" ref-type="bibr">Konovsky 2000</xref>). Thus, workers’
perception of injustice was observed to have contributed to a lack of commitment and
anti-citizenship behaviour that was counterproductive to the achievement of
organizational goals. We observed that in part at least, as a consequence of these
perceptions that the organization was not interested in their welfare as people,
there was low worker motivation that had led to attitudes that created tensions and
contributed to poor organizational climate and poor worker collaboration in health
care provision. Ultimately, it affected worker response to clients’ needs.
Some workers had adopted strategies including doing locum<xref ref-type="fn" rid="czu068-NT20"><sup>20</sup></xref> in private facilities, charging clients
illegal fees or reporting to work late or leaving work early.<xref ref-type="fn" rid="czu068-NT21"><sup>21</sup></xref> Sometimes such attitudes led to delays in
responding to clients’ needs, due to poor collaboration among different
categories of professionals providing services such as Caesarean sections (CS). An
illustration is a junior doctor who had to wait for nurses, orderlies and an
anaesthetist on afternoon shift to arrive to work with him to perform a CS on a
client who was admitted the previous day and needed an emergency CS. In response to
a question on factors demotivating him he expressed his frustration as follows:
<disp-quote content-type="extract"><p>“Look at that woman lying there (a
pregnant woman set with infusion is lying on a bed in the walkway), she has
been in labour since Sunday (this was a Monday afternoon), but now we cannot
perform CS on her, because it is 1:30 pm and the morning shift people say
they have to close.”<xref ref-type="fn" rid="czu068-NT22"><sup>22</sup></xref></p></disp-quote> Ideally the morning shift
should have worked with the doctor till the afternoon shift took over at 2.00 pm.
This kind of situation has been observed elsewhere (<xref rid="czu068-B33" ref-type="bibr">Mansour <italic>et al.</italic> 2005</xref>; <xref rid="czu068-B37" ref-type="bibr">Heponiemi <italic>et al.</italic> 2010</xref>).
Still related to these observations, but in the contrary direction, other studies
have found that where workers had trust in management, it reflected in a positive
relationship between workers and their clients (<xref rid="czu068-B16" ref-type="bibr">Bruce 1990</xref>; <xref rid="czu068-B40" ref-type="bibr">Koenig <italic>et al.</italic> 1997</xref>; <xref rid="czu068-B65" ref-type="bibr">Westaway <italic>et al.</italic> 2003</xref>; <xref rid="czu068-B12" ref-type="bibr">Atinga <italic>et al.</italic>2011</xref>).</p><sec><title>Perceived distributive injustice related to wider health sector issues at
national level</title><p><xref rid="czu068-B28" ref-type="bibr">Folger (1993)</xref> suggests that when
employees perceive that their organization cares about them as human beings,
they are more likely to trust the organization, exhibit greater loyalty and
commitment to work and the contrary is true. Many of the frontline workers in
this study perceived injustice at a wider health sector level that is the
central Ministry of Health, GHS and its regional health service directorates.
They suggested that the sector was not responsive to their health care needs,
work-related injuries and providing them with a conducive work environment.
Frontline workers’ perceptions of injustice at sector level sometimes
intersected with their perceptions of injustice at hospital management
level.</p><p>Frontline workers suggested that the Ministry of Health, GHS and their facility
managers did not care about their welfare. Consequently, they did not trust that
GHS and their facilities would take care of them if they risked their lives in
the line of duty. Frontline workers’ lack of trust was sometimes exhibited
in worker–client interaction. The observation below is an illustration of
one of such incidents in a maternity ward. A mentally challenged client was in
labour, but she was not co-operating with a senior nurse, who wanted to conduct
a vaginal examination. A junior nurse discouraged the senior nurse from
continuing her efforts by saying: <disp-quote content-type="extract"><p>“If she will not agree…. leave her.…If you force
to examine her and she resists, you could injure yourself…. Ghana
Health Service will not do anything for you. You will even have to take
care of yourself, buy your own drugs, treat yourself and no one will
compensate you.”<xref ref-type="fn" rid="czu068-NT23"><sup>23</sup></xref></p></disp-quote> Interviews with
management workers suggested that there was a work policy guideline for adverse
events to ensure that workers who got injured were catered for.<xref ref-type="fn" rid="czu068-NT24"><sup>24</sup></xref> However, workers who
were injured or exposed to HIV/AIDs and Hepatitis B in the process of providing
health care said they had to bear the cost of treatment. A doctor in Facility A
who experienced needle pricks on three occasions while performing surgery on
HIV/AIDS clients said he had to pay for the cost of treatment.<xref ref-type="fn" rid="czu068-NT25"><sup>25</sup></xref> A nurse in Facility B
also narrated her experience as follows: <disp-quote content-type="extract"><p>“If a worker is sick even paracetamol (a painkiller usually
administered as first aid) you have to buy…Last year I was doing
delivery and had to do episiotomy. While I was suturing, I suffered a
needle prick. Unfortunately, the client was hepatitis B
positive….I had to do some tests… I also had to go for
hepatitis B vaccination and the disease control officer charged me 15
Ghana Cedis (US$7) for each of the three shots.”<xref ref-type="fn" rid="czu068-NT26"><sup>26</sup></xref></p></disp-quote> The researcher interviewed a legal
expert to understand whether workers had a right to demand treatment for
injuries at work and better conditions of service. He said that the Ghana labour
act stipulates that the health of the employee is the concern of the employer.
So workers had the right to demand better conditions of service. He added that
it was more rewarding to the organization to provide such basic services to
their frontline workers, because it served as a booster to worker
performance.<xref ref-type="fn" rid="czu068-NT27"><sup>27</sup></xref></p><p>Frontline workers in Facility A perceived distributive injustice from the
regional health directorate and hospital management in the allocation of
frontline workers especially doctors to the maternity department of Facility A.
Facility A conducts over 200 deliveries in a week. At the time of the field
work, it had three specialist obstetrician gynaecologists and three general
doctors. Additionally, an average of three house officers (newly qualified
doctors on internship) were posted to Facility A’s maternity department
periodically to do 3- to 6- month internship under the supervision of
specialists. Doctors complained of unfair distribution of doctors and work
between them and their colleagues in the teaching hospitals. They suggested that
in comparison, the teaching hospitals attended to only a slightly higher number
of maternity cases than they did, yet had about seventy doctors in their
maternity departments compared with the six in Facility A’s maternity
department.<xref ref-type="fn" rid="czu068-NT28"><sup>28</sup></xref></p><p>Some suggested that the regional health directorate was unresponsive to their
need for doctors, despite efforts put in by the maternity department to bring
their predicament to its notice. Conversation with some doctors in the maternity
department and an interview with a doctor who left the facility suggested that
an assessment of the quantum of work by the regional health directorate
recommended that the maternity department be staffed with 25 doctors. But the
regional health directorate did not provide the recommended number of doctors.
They perceived this development as unfair, because the 6 doctors available had
to take on the work of 25 doctors.<xref ref-type="fn" rid="czu068-NT29"><sup>29</sup></xref></p><p>The consequences of unfair distribution of doctors included work overload,
doctors feeling overused, complaints of ill health, tiredness and waning
motivation. Some devised coping strategies including switching their phones off
when off duty and refusing to visit some of the wards in the maternity
department during ward rounds. Some placed quotas for the number of clients they
would attend to in a day.<xref ref-type="fn" rid="czu068-NT30"><sup>30</sup></xref> The findings supports <xref rid="czu068-B50" ref-type="bibr">Manongi <italic>et al.</italic> (2006)</xref> and <xref rid="czu068-B52" ref-type="bibr">Mbindyo <italic>et al.</italic>’s
(2009)</xref> studies, which suggest that health workers give quotas when
they are overwhelmed with work. Others performed only emergency CS and skipped
elective CS, while some left, giving the maternity a relatively high doctor
turnover. An interview with Dr Job* who was described as a good doctor, but
left Facility A depicts the process from feelings of injustice to demotivation
to attrition. <disp-quote content-type="extract"><p> “I got
tired…It gets to a point you begin to feel that those managing
the system don’t really care about those who are busily doing the
work. So whether you go to work and there is no water or whether you go
to work and the laundry is not functioning, whether you go to work and
the unit that sterilizes the equipment is not functioning, whether you
have enough medical officers or house officers to support you do the
work or not, nobody seemed to be finding permanent solutions to these
problems. So once in a while we run into different forms of
crisis… and then you find out that you are getting more and more
irritated with everybody who work with you. You snap at nurses, you snap
at patients. You get up in the morning, particularly on the days that
you are going on calls, you are not happy to be going to
work.”<xref ref-type="fn" rid="czu068-NT31"><sup>31</sup></xref></p></disp-quote> A senior nurse manager
explained that the limited number of doctors in the maternity department of
Facility A was a national problem. She explained that there are quotas imposed
on the number of workers that the GHS can employ at a given time. Second, the
teaching hospitals, which are the training institutions that feed public
hospitals with doctors, retain most of the doctors they train.<xref ref-type="fn" rid="czu068-NT32"><sup>32</sup></xref> The skewed distribution
of doctors in low resource countries including Ghana has been noted elsewhere
(<xref rid="czu068-B24" ref-type="bibr">Dovlo 1998</xref>; <xref rid="czu068-B4" ref-type="bibr">Agyepong <italic>et al.</italic>2001</xref>; <xref rid="czu068-B18" ref-type="bibr">Chen <italic>et al.</italic>2004</xref>; <xref rid="czu068-B61" ref-type="bibr">Snow <italic>et
al.</italic> 2012</xref>; <xref rid="czu068-B27" ref-type="bibr">Faye
<italic>et al.</italic> 2013</xref>; <xref rid="czu068-B56" ref-type="bibr">Mutale <italic>et al.</italic> 2013</xref>). Unfortunately,
in many countries the establishment of posts, recruitment, terms and conditions
of service are beyond the authority of public hospitals and regional managers.
They are directly controlled by central government agencies (<xref rid="czu068-B42" ref-type="bibr">Larbi 1998</xref>, <xref rid="czu068-B43" ref-type="bibr">2005</xref>; <xref rid="czu068-B11" ref-type="bibr">Appiah-Denkyira <italic>et al.</italic> 2011</xref>). Second per the GHS
and Teaching Hospitals’ Act 525 (<xref rid="czu068-B35" ref-type="bibr">Government of Ghana 1996</xref>), the regional health directorate and the
GHS have no authority over doctors in the teaching hospitals, which are a major
source of recruitment of doctors and other frontline workers. These gaps are
translated into skewed distribution of doctors in public health facilities as
was the case in Facility A.</p><p>Frontline workers in the maternity department of both facilities perceived
distributive injustice in national policy related to worker remuneration. They
suggested that since they were attending to higher client numbers than their
colleagues in other departments, they should be given incentives to make up for
the low remuneration from government.<xref ref-type="fn" rid="czu068-NT33"><sup>33</sup></xref> A senior doctor in the maternity department of
Facility A presented this view: <disp-quote content-type="extract"><p>“Dr
Kofi: The Ghana Health Service system is such that the physician
specialist and the gynaecologist receive the same salary. But the
physician specialist will come in the morning, do the prescriptions and
by afternoon he is done… But our work is different; you can be
called at any time .…sometimes they call me at 2:30 am.</p><p>Researcher: So do you think your midwives have a case when they complain
that they are not being treated fairly?</p><p>Dr. Kofi*: Yes, their complaints are right. Because they work a lot,
but are not given much…the problem is a national one. For
instance workers of the same rank are given the same salary across the
country. So a nurse of the same rank whether the fellow is in the labour
ward, the out patients department or wherever receives the same
salary.”<xref ref-type="fn" rid="czu068-NT34"><sup>34</sup></xref></p></disp-quote> A member of management in
Facility A agreed that the quantum of work in the maternity department was
comparatively higher than in the other departments, so the workers in the
maternity department should be compensated for the extra work.<xref ref-type="fn" rid="czu068-NT35"><sup>35</sup></xref> However, a senior nurse
manager in Facility A and two management workers in Facility B held the view
that all departments are important, so they should be treated equally. The
priority should be on using the IGFs to run the hospital and any surpluses could
be used to provide incentives to motivate all workers.<xref ref-type="fn" rid="czu068-NT36"><sup>36</sup></xref></p><p>Another national policy issue cited by workers as unjust both from a distributive
and procedural injustice perspective was the implementation of the fee free
delivery policy, which involved universal exemptions from payment of user fees
for delivery services (<xref rid="czu068-B10" ref-type="bibr">Ansong-Tornui
<italic>et al.</italic> 2007</xref>). Frontline workers in Facility A
suggested that the policy had led to an increased client load in the maternity
department, without a corresponding increase in staff numbers, basic equipment,
tools and supplies, worker remuneration and expansion of infrastructure. This
was unfair. To use the words of one of the senior doctors: <disp-quote content-type="extract"><p>“I am disgruntled and angry but we have to
work. They refused to give us our conversion difference (salary
adjustment).…Look at the clients; some are sitting on benches.
Facility A, two thirds of the land has not been used, we have a large
plot of land and what is being done with it! Look at the small thing
they are putting up as the maternity block and look at how long it has
taken.”<xref ref-type="fn" rid="czu068-NT37"><sup>37</sup></xref></p></disp-quote> Workers perceived that the
national policy on the fee free delivery service had been implemented without
taking into consideration the ability of facilities and workers to manage excess
numbers or how to compensate workers for the extra work. The increase in numbers
had put a strain on workers and facilities, which was demotivating. Similar
finding have been reported (<xref rid="czu068-B10" ref-type="bibr">Ansong-Tornui
<italic>et al.</italic> 2007</xref>). Other studies have documented
frontline workers’ perceptions of unfair remuneration with agitations for
better remuneration in Ghana (<xref rid="czu068-B5" ref-type="bibr">Agyepong
<italic>et al.</italic> 2012</xref>). <xref rid="czu068-B62" ref-type="bibr">Songstad <italic>et al.</italic> (2011)</xref> also noted
the influence of policy and political developments on worker remuneration and
perceptions of injustice in Tanzania.</p></sec><sec><title>Perceived interactional injustice related to hospital management</title><p>In Facility B, many frontline workers perceived interactional injustice from
hospital management in meting out punishments and rewards and in communicating
with workers. Frontline workers suggested that the head of the hospital did not
commend them for good work done, but was quick to reproach (insult) workers who
made mistakes. They found her approach to interacting with them unprofessional
and demotivating.<xref ref-type="fn" rid="czu068-NT38"><sup>38</sup></xref> An
interview with two management workers confirmed frontline workers’
perceptions about the head. The management workers added that if a worker made a
mistake, the head of the facility insulted the worker and also insulted his or
her entire family. Also if the worker in question ever made another mistake in
future, the head always referred to her previous mistakes.<xref ref-type="fn" rid="czu068-NT39"><sup>39</sup></xref> A senior nurse said she had indicated
in a staff survey questionnaire in 2013 that they were not commended for their
good work, but were always reproached by the hospital management for
shortcomings.<xref ref-type="fn" rid="czu068-NT40"><sup>40</sup></xref></p><p>The management workers who were interviewed as well as the frontline workers
admitted that the head of the hospital had the right to discipline workers.
However, they said they would have preferred an approach to discipline with the
head appropriately investigating reported offences first, then dealing with the
offences in a professional way, instead of making discipline seem like a
personal attack on workers. They argued that dealing with offences in a
professional manner could help bring long-term solutions and prevent recurrence
of similar offences.<xref ref-type="fn" rid="czu068-NT41"><sup>41</sup></xref>In an interview with the researcher, the head of Facility B said that she
follows the GHS code of ethics<xref ref-type="fn" rid="czu068-NT42"><sup>42</sup></xref> to discipline offending workers. This entails: she
first gives a verbal warning to an offender, followed by a written warning and
the third time she hands the offender over with the compiled evidence to the
district health directorate or the regional health directorate for action. On
the issue of workers complaining that she reproaches them for their offences,
she explained that once a worker commits an offence, she reprimands the worker
in her office in the presence of the worker’s department head who serves
as a witness. However, if the fellow repeats a similar offence she refers the
worker to the previous offence, because the worker would have probably promised
to be of good behaviour, but might have forgotten and committed a similar
offence.<xref ref-type="fn" rid="czu068-NT43"><sup>43</sup></xref></p><p>Some workers suggested that existing channels for communicating concerns to
management were not helpful. A former management worker said they had
durbars,<xref ref-type="fn" rid="czu068-NT44"><sup>44</sup></xref> which
were not useful channels for communicating their concerns to management. He said
frontline workers complained that in previous durbars when they raised their
concerns, the head of the facility responded in an unfriendly manner.
Consequently, very few workers attend durbars.<xref ref-type="fn" rid="czu068-NT45"><sup>45</sup></xref> The head of Facility B said in an
interview that she did not see her responses at durbars as a confrontation; this
was probably the perception of some workers. She stated that she and her core
management team members make efforts to address workers’ concerns at
durbars.<xref ref-type="fn" rid="czu068-NT46"><sup>46</sup></xref></p><p>Thus ironically workers felt that the professional work ethics that they were
being espoused to hold for their clients, were not being reciprocated to them by
the hospital management. Perceived interactional injustice contributed to
feelings of bitterness, sorrow and anger, which affected some workers’
self confidence, interest and desire to perform their duties.<xref ref-type="fn" rid="czu068-NT47"><sup>47</sup></xref> Consequently, some workers did not
take initiatives to facilitate health service provision to clients and sometimes
counterproductive behaviours were observed. On one occasion women who had
completed their antenatal visit could not leave the facility, because they had
to take their drugs from the antenatal pharmacy. However there was no dispensary
attendant, so the women sat waiting for another hour. The junior nurse who
provided them with the antenatal service got worried and asked her superior if
they could do anything about the women’s plight since there was no
dispensary attendant at the dispensary to attend to them. The superior
responded: ‘I don’t care what happens. If I talk then they will
report me to doctor (head of Facility B). So I won’t bother
myself.’<xref ref-type="fn" rid="czu068-NT48"><sup>48</sup></xref>Subsequently, the women who overheard her comment left the facility without
waiting any longer to receive their routine antenatal drugs.</p><p>Workers’ perception of being treated with disrespect and in an insensitive
manner contributed to poor organizational climate and lack of job satisfaction
and the desire to leave the facility. Similar findings have been noted elsewhere
(<xref rid="czu068-B44" ref-type="bibr">Laschinger 2003</xref>, <xref rid="czu068-B45" ref-type="bibr">2004</xref>; <xref rid="czu068-B8" ref-type="bibr">Almost <italic>et al.</italic> 2010</xref>). Also, <xref rid="czu068-B51" ref-type="bibr">Mathauer and Imhoff (2006)</xref> found
that appreciation of their work and recognition among others were important
ingredients to worker motivation and a perceived sense of justice. <xref rid="czu068-B29" ref-type="bibr">Fonn and Xaba (2001)</xref> infer that when
health system managers treat workers fairly respecting their rights, empowering
them and creating a conducive work environment, workers become motivated and
exhibit positive attitudes towards work.</p><sec><title>Intrinsic motivation factors</title><p>Most frontline workers perceived injustice at hospital management and policy
levels, which they suggested affected their motivation. However,
interestingly some of these workers demonstrated a high sense of motivation
and responded positively to clients’ needs in spite of this. In-depth
interviews and conversations with some workers who were observed to exhibit
a high sense of motivation suggested that the factors motivating them were
intrinsic. Intrinsically motivating factors were similar in both facilities.
Sources of workers’ intrinsic motivation included perceiving clients
as human beings with rights and the desire to maintain standards and
accountability to God for one’s actions. Others were a perception of
their work as a contract that must be honoured, a strong sense of duty and
the obligation to use their professional knowledge ethically. Some
intrinsically motivated workers suggested that the greatest incentives to
them included successful client recovery, which gave them an inner sense of
satisfaction and others believed they received blessings from God for
responding positively to clients’ needs. Below are illustrative
excerpts from two workers. The first is a doctor in Facility A, whose
motives were clients’ rights, a high sense of duty and a desire to
maintain standards. The second is a nurse in Facility B whose motives
included professional ethics and deriving inner satisfaction from successful
outcomes. <disp-quote content-type="extract"><p>“I don’t want to
mismanage anyone. I don’t want to give half-half to anyone. I
don’t want to see someone and it is like you are
experimenting, no. If I see you, I want to give you the very best I
can and standard treatment that you deserve. Not because you are in
Ghana, so you don’t have this, no.… I don’t want
to cut corners.”<xref ref-type="fn" rid="czu068-NT49"><sup>49</sup></xref></p><p>You see, I believe that when you are doing a job you have to do it
well. When I came here (Facility B) the first time, I realized that
there was no oxygen and I said I won’t work without oxygen.
The then matron… had to get it before I became comfortable to
work here. You know, when you are working, the inner satisfaction is
very important. How can you deliver a mother and the baby needs
resuscitation and you cannot do so and you watch the baby die.<xref ref-type="fn" rid="czu068-NT50"><sup>50</sup></xref></p></disp-quote></p><p>These two workers and several others like them who were intrinsically
motivated exhibited positive attitudes including sacrificing to stay back to
attend to clients past their scheduled times. In emergencies, some used
their personal resources including going to other hospitals to beg for
supplies for their hospital. Some improvized in the absence of critical
supplies to save lives.<xref ref-type="fn" rid="czu068-NT51"><sup>51</sup></xref> The influence of intrinsic motivation on worker
performance is consistent with <xref rid="czu068-B48" ref-type="bibr">Lin’s (2007)</xref> finding that workers’ attitudes and
intentions to perform tasks are strongly associated with their intrinsic
motivation. Studies in Benin suggests that vocation, professional
conscience, job satisfaction and the desire to help clients are strong
motivating factors for health workers (<xref rid="czu068-B51" ref-type="bibr">Mathauer and Imhoff 2006</xref>). Studies carried out
in India found that intrinsic factors had a higher influence on
doctors’ motivation in the provision of health care than extrinsic
factors (<xref rid="czu068-B59" ref-type="bibr">Purohit and Bandyopadhyay
2014</xref>).</p></sec></sec></sec><sec><title>Summary of findings</title><p>Our findings support studies that suggest that workers’ motivation is
influenced by extrinsic and intrinsic factors. We found that perceptions of
distributive, procedural and interactional injustice at organizational and policy
levels had a strong influence on workers’ motivation and response to
clients’ health care needs. Frontline workers had the feeling of being let
down by the health system as they perceived that they did not receive
‘people-centred care’ from their employers, despite being asked to
provide ‘people-centred care’ to the clients that come to their
hospitals. They perceived that the values they are being asked to hold for their
external customers are not being held for them by the health system within which
they work. This considerably weakens the credibility of the message they are being
given to treat their clients in a responsive manner. Furthermore, perceived
injustice in policy and organizational processes made them distrust their
leadership. Some became apathetic and less motivated to respond to external
clients’ needs.</p><p>Despite perceived injustice in policy and organizational processes, some workers
demonstrated a high sense of motivation and responded positively to clients’
health care needs. We found that intrinsic motivation factors including perceiving
clients as human beings with rights, the desire to maintain standards and
accountability to God for one’s actions among others, played a key role in
workers who demonstrated a high sense of motivation. Intrinsically motivated workers
suggested that they derived inner satisfaction from performing tasks and others
believed that they received blessings from God for responding to clients’
needs. Nevertheless, even intrinsically motivated workers such as Dr Job* burned
out with time. This shows that worker motivation is a dynamic process.</p></sec><sec sec-type="conclusions"><title>Conclusion</title><p>Our methodology of a participatory approach through participant observation,
conversations and in-depth interviews in studying frontline worker motivation in a
biomedical environment provides insights on organizational justice in the hospital
environment that could not have been otherwise obtained.</p><p>Using distributive, procedural and interactional justice dimensions of organizational
justice theory, this study has demonstrated the multiple layers of injustice
perceived by health workers in the hospital setting. It brings to light the
influence of worker perception of injustice on worker motivation in the provision of
health care. Where workers perceived injustice, workers were more likely to be
demotivated and it affected their response to client health care needs. However,
issues of injustice could not explain why some workers were motivated to respond to
clients’ needs. Factors that were identified to motivate workers were
intrinsic. Thus, this study contributes to knowledge on the complexity of factors
that influence frontline worker motivation within the hospital setting.</p><p>To promote worker motivation a ‘people-centred care’ approach that
considers frontline workers within health system as ‘people’ to whom the
system should be responsive is essential. Health care should draw upon CQI
philosophy and should be organized around health workers as internal customers and
clients as external customers. Frontline workers’ interest should be factored
into any intervention that aims at improving quality health care.</p><p>Within our study setting a ‘people-centred’ approach that includes
frontline health workers in the concept should include the following:</p><p>At facility level, supportive leadership and supervision should be instituted to
foster good working relationships between frontline workers and managers. There is a
need to train managers in transparency, communication, respect in interaction and
the need to see team work as a priority as proposed in the CQI philosophy.</p><p>At facility level a radical change in management culture is needed. Management should
put in structures that will ensure effective communication, transparency and
accountability. Also, managers and supervisors should learn to see workers as
members of a team who should be treated with dignity and respect even in matters of
discipline. Facilities should improve motivation through provision of basic
incentives to frontline workers.</p><p>At national and regional levels efforts should be made to synchronize the needs of
the various facilities to be able to distribute frontline workers based on need of
facilities. Transparent processes for allocating workers that engage frontline
workers and are seen as fair in the context of overall national resource constraints
should be adopted.</p><p>We believe that without the creation of a conducive atmosphere where frontline
workers will feel their concerns are that of their departmental organization
managers, policy makers and other agents responsible for health care in a way that
is fair, it will be difficult to have frontline workers motivated to see the health
of their clients as their concern.</p></sec></body><back><ack><title>Acknowledgements</title><p>We thank the Netherlands Organization for Scientific Research for funding for the
research work. Also, we thank the Greater Accra Regional Health Directorate and
participating institutions and workers for their support and co-operation. We
acknowledge former employees of the two institutions who granted interviews for the
study. We equally thank the two anonymous reviewers who painstakingly reviewed this
manuscript to improve the quality.</p></ack><sec><title>Funding</title><p>This work was funded by the <funding-source>Netherlands Organization for Scientific
Research (NWO/WOTRO)</funding-source> on the project Accelerating progress
towards attainment of <funding-source>Millennium Development Goals
(MDG)</funding-source> 4 and 5 in Ghana through basic health systems function
strengthening, grant number (<award-id>WOTRO-IP W 07.45.102.00</award-id>)</p><p><italic>Conflict of interest statement</italic>. None declared.</p></sec><sec><title>Ethical approval</title><p>Ethical approval was obtained from the University of Wageningen and the GHS ethical
review boards. The Greater Accra regional health directorate approved the study. The
regional health directorate wrote letters to the two district health directorates
that have oversight responsibility over the district hospitals where the study was
conducted. The district health directorates equally approved the study and forwarded
copies of the letters to the study hospitals, whose heads then granted clearance for
the study in their facilities. The researcher was then introduced to the heads of
the maternity departments and the individual wards in the department as a student
researcher. They were informed of the objectives of the study and they gave her
their permission to work in the wards. She was also given permission to observe
activities and to participate in meetings, training programmes and other activities
in the departments. The researcher was introduced to the frontline workers including
nurses, doctors, anaesthetists, ward aids and orderlies in the wards. This helped
her to gain trust and to interact freely with workers. Written consent was obtained
from interview participants, while verbal consent was obtained for conversations
with study participants. To protect the identity of the facilities and participants
pseudonyms have been used.</p></sec><notes id="notes1"><title>Endnotes</title><fn-group><fn id="czu068-NT1"><p><sup>1</sup> Facility A: observation notes, May 24, 2012.</p></fn><fn id="czu068-NT2"><p><sup>2</sup> Facility A: conversation with a doctor, May 7, 2012;
Conversation with a midwife, July 27, 2012; Interview with a nurse,
September 20, 2012; Observation notes, May 24, 2012.</p></fn><fn id="czu068-NT3"><p><sup>3</sup> Facility A: conversation with an anaesthetist, July 5, 2012.</p></fn><fn id="czu068-NT4"><p><sup>4</sup> Interview with Dr *Bill, former worker of Facility A,
September 9, 2013.</p></fn><fn id="czu068-NT5"><p><sup>5</sup> Facility A: interview with an accountant, August 17, 2012.</p></fn><fn id="czu068-NT6"><p><sup>6</sup> Facility A: conversation with a senior midwife, June 8, 12.</p></fn><fn id="czu068-NT7"><p><sup>7</sup> Facility A: interview with Hospital manager, December 4,
2013.</p></fn><fn id="czu068-NT8"><p><sup>8</sup> Facility B: Conversation with a nurse, August 22, 2012;
Conversation with a nurse, July 29, 2013; Conversation with two night
nurses, August 11, 2013.</p></fn><fn id="czu068-NT9"><p><sup>9</sup> An annual performance review of public hospitals in the Greater
Accra Region. This was instituted by the regional health directorate to
improve health care quality.</p></fn><fn id="czu068-NT10"><p><sup>10</sup> Facility B: interview with two management members, August 6,
2013; conversation with two nurses, August 11, 2013.</p></fn><fn id="czu068-NT11"><p><sup>11</sup> Facility B: conversation with two night nurses, August 11,
2013.</p></fn><fn id="czu068-NT12"><p><sup>12</sup> Facility A: observation notes, maternal audit meeting, March
16, 2013.</p></fn><fn id="czu068-NT13"><p><sup>13</sup> Facility A: conversation with an anaesthetist, July 5,
2012.</p></fn><fn id="czu068-NT14"><p><sup>14</sup> Facility A: conversation with an anaesthetist, October 3, 2013;
Facility B: conversation with a nurse, September 26, 2012.</p></fn><fn id="czu068-NT15"><p><sup>15</sup> Facility A: conversations with two anaesthetists, October 3,
2013, September 26, 2013; Facility B: interview with senior nurse, July 30,
2013.</p></fn><fn id="czu068-NT16"><p><sup>16</sup> Facility A: interview with a management member, July 31,
2012.</p></fn><fn id="czu068-NT17"><p><sup>17</sup> Ocytocin is a drug commonly used in induction and argumentation
of labouring clients (<xref rid="czu068-B32" ref-type="bibr">Freeman and
Nageotte 2007</xref>).</p></fn><fn id="czu068-NT18"><p><sup>18</sup> Facility B: interview with two management members, August 6,
2013.</p></fn><fn id="czu068-NT19"><p><sup>19</sup> Facility A: conversation with an anaesthetist, July 5,
2012.</p></fn><fn id="czu068-NT20"><p><sup>20</sup> Locum is working in private facilities in addition to being
permanent workers in public hospitals.</p></fn><fn id="czu068-NT21"><p><sup>21</sup> Facility B: conversation with a nurse, July 18, 2013; Interview
with Dr Job, August 3, 2013.</p></fn><fn id="czu068-NT22"><p><sup>22</sup> Facility A: conversation with a junior doctor, July 23,
2012.</p></fn><fn id="czu068-NT23"><p><sup>23</sup> Facility A: observation notes, September 14, 2012.</p></fn><fn id="czu068-NT24"><p><sup>24</sup> Facility A: interviews with a management member, July 31, 2012;
Facility B: interview with two management members, September 20, 2013.</p></fn><fn id="czu068-NT25"><p><sup>25</sup> Facility A: interview with a junior doctor, September 14,
2012.</p></fn><fn id="czu068-NT26"><p><sup>26</sup> Facility B: interview with senior nurse, July 30, 2013.</p></fn><fn id="czu068-NT27"><p><sup>27</sup> Interview with legal expert, September 8, 2013.</p></fn><fn id="czu068-NT28"><p><sup>28</sup> Facility A: observation notes, November 23, 2012.</p></fn><fn id="czu068-NT29"><p><sup>29</sup> Facility A: conversation with two gynaecologists, a junior
doctor and a house officer, April 30, 2012; interview with Dr Job*,
August 3, 2013.</p></fn><fn id="czu068-NT30"><p><sup>30</sup> Facility A: interview with a junior doctor, October 31,
2012.</p></fn><fn id="czu068-NT31"><p><sup>31</sup> Interview with Dr Job*, August 3,2013.</p></fn><fn id="czu068-NT32"><p><sup>32</sup> Facility A: conversation with senior nurse, November 26,
2013.</p></fn><fn id="czu068-NT33"><p><sup>33</sup> Facility A: conversation with two nurses, April 20, 2012.</p></fn><fn id="czu068-NT34"><p><sup>34</sup> Facility A: conversation with a senior doctor, July 5,
2012.</p></fn><fn id="czu068-NT35"><p><sup>35</sup> Facility A: interview with physician specialist, July 31,
2012.</p></fn><fn id="czu068-NT36"><p><sup>36</sup> Facility A: interview with a nurse, September 20, 2012;
Facility B: interview with two management members, August 6, 2013.</p></fn><fn id="czu068-NT37"><p><sup>37</sup> Facility A: conversation with a senior doctor, October 3,
2013.</p></fn><fn id="czu068-NT38"><p><sup>38</sup> Facility B: interview with a doctor, July 29, 2013; interview
with two nurses July 30, 2013; conversation with a nurse, July 29, 2013.</p></fn><fn id="czu068-NT39"><p><sup>39</sup> Facility B: interviews with two management members, August 6,
2013.</p></fn><fn id="czu068-NT40"><p><sup>40</sup> Facility B: interview with a nurse, July 30, 2013.</p></fn><fn id="czu068-NT41"><p><sup>41</sup> Facility B: interview with two management members, August 6,
2013; interview with a doctor, July 29, 2013; Conversation with a nurse,
July 29, 2013.</p></fn><fn id="czu068-NT42"><p><sup>42</sup> The GHS code of conduct and disciplinary procedures stipulates
how matters of workers discipline should be handled by health service
managers. <xref rid="czu068-B80" ref-type="bibr">GHS 2003</xref>. Code of
Conduct and disciplinary Procedures, Accra, Ghana.</p></fn><fn id="czu068-NT43"><p><sup>43</sup> Facility B: interview with hospital manager, March 5, 2014.</p></fn><fn id="czu068-NT44"><p><sup>44</sup> Open air meetings that brings together management and frontline
workers to interact freely to discuss organizational issues.</p></fn><fn id="czu068-NT45"><p><sup>45</sup> Facility B: interview with former management member, August 7,
2012.</p></fn><fn id="czu068-NT46"><p><sup>46</sup> Facility B: interview with hospital manager, March 5, 2014.</p></fn><fn id="czu068-NT47"><p><sup>47</sup> Facility B: interview with a medical doctor, July 29, 2013;
Interview with two nurses, July 30, 2013; conversation with a nurse, July
29, 2013.</p></fn><fn id="czu068-NT48"><p><sup>48</sup> Facility B: observation notes, July 18, 2013.</p></fn><fn id="czu068-NT49"><p><sup>49</sup> Facility A: interview with a junior doctor, September 14,
2012.</p></fn><fn id="czu068-NT50"><p><sup>50</sup> Facility B: conversation with a nurse, September 5, 2012.</p></fn><fn id="czu068-NT51"><p><sup>51</sup> Facility A: observation notes, July 3, 2012, September 17,
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