Value of training on motivation among health workers in Narok County, Kenya

Introduction Training, as an additive human resources intervention is decisive to organizational performance. Employees require constant update of formal and informal knowledge alongside positive attitudes that have been defined as necessary in motivation leading to effectiveness in performance hence workplace training is tied to achieving organizational aims and objectives. The objective of this study was to determine the influence of training on motivation among health workers in Narok County, Kenya. Methods A cross-sectional study utilizing a self administered questionnaire, targeting 237 health workers and 21 health managers was used. Data analysis was done using SPSS version 21 using descriptive statistics. Factor analysis was done on the training perception in relation to motivation. Results Majority of the respondents rated their motivation between 7 and 9 in the current health facility (35.4%), Sub-county (33.8%) and County (32.9%) with the median motivation level of 5. Majority of health workers 194 (81.9%) had received a form of training, of whom 191 (98.5%) indicated that on-job training was relevant to their tasks and that it motivated 192 (99.0%) of them to perform better due to coining skills to motivation. Training significantly predicted general motivation (p-value = 0.013), job satisfaction (p-value = .001), intrinsic job satisfaction (p-value = .001) and organisational commitment (p-value <.001). Conclusion The researchers concluded that there is a relationship between training and motivated health workforce in Narok County and recommended strengthening of current training initiatives by ensuring trainings are more regular and involvement of health workers in discussing their career development prospects.


Introduction
Training in a work organization is essentially a learning process, in which learning opportunities are purposefully structured by the management and training staff working in collaboration [1]. The aim of the process is to develop in the organization's employees the knowledge, skills and attitudes that have been defined as necessary to motivate them to effectively perform their work and hence the achievement of organizational aims and objectives. Employers therefore depend on the quality of their employees´ performance to achieve organizational aims and objectives. Training has been used to upgrade skills and knowledge in the health care sector in resource poor settings as off-site training courses and seminars. As an intervention to motivate and improve practices of health providers, it has not proven to be very effective due to a lack of problem analysis and training-needs assessment [2,3]. There is a notion that training has an association with disparities reflected in training content and skills needed in the work environment, as well as methods involved in its delivery [4]. Other than the methods of delivering training, actual access of training among health workers vary [5]. In Kenya it has been observed that health workers in the public sector have limited access to training and further qualifications is limited or granted in line with reasons that are not equitably available or merit-based, this can likewise have detrimental consequences for the motivation effect of training as a tool of HRM [4]. Inadequate knowledge, skills and inappropriate attitudes can all form obstacles to good health care. As a result, advances in insights into treatment and diagnosis, as well as changes in roles and responsibilities, require continuous professional development among health workers and this serves as a motivator.
According to the World Health Organization [6], a lifelong learning process must be developed at the start of a professional career in the health sector in order to realize better health benefits. The benefits of training are many: improves morale of employees, helps the employee to get job security and job satisfaction, helps refreshing past knowledge and practice, and helps to identify and correct mistakes [7,8].
This study was necessitated by the relatively sub optimal performance on key health indicators related to maternal and child health [9]. Health workers are important human resources (HR) that will contribute to realizing the health part of the Millennium Development Goals (MDGs) [10]. In Kenya, the health sector is pivotal to achievement of vision 2030 [11] and as a third world country with limited resources for providing quality health services for all of its citizens, success in providing quality health care should involve developing innovative strategies to meet the health objective. Part of these innovations is to develop strategic human resource management (HRM) interventions proven to motivate health workers in order to ensure prudent use of the minimal resources available. At the time of the study, the authors were unaware of any published reports on the influence of training on motivation among health workers in Narok County, Kenya.
Considering that training is an important input in HRM which has an impact on quality healthcare delivery and contributes to strengthening the HR pillar of every health system [12], the study was carried out to document the status of the influence of training amongst health workers serving in public health facilities in Narok County, Kenya. In the current devolved health care system in the country which is relatively a new dispensation in healthcare, these findings would contribute in identifying if training is really a priority area of intervention in motivating health workers thereby providing evidence to County health managers on appropriate investments known to improve performance in order to maximize on resources available for greater health benefit.  Participants' privacy was maintained by ensuring that they were not exposed to public when filling questionnaires. Anonymity of respondents was assured by concealing their identity and research data was kept confidential for research purposes only. The study was conducted by full adherence of the Scientific and Ethics Review

Methods
Committee of Kenya Methodist University.

Results
Motivation level of health workers: On a scale of 1 (fully demotivated) to 10 (fully motivated), majority of the respondents rated their motivation as between 7 and 9 in the current health facility (35.4%), Sub-county (33.8%) and County (32.9%) as shown in Figure 1. The median motivation level was rated as 5 (implying averagely motivated) at the current health facility, Sub-county and County. There was significant difference in the motivation levels at the current health facility, sub-county and County (Friedman test pvalue < .001). Based on a scale of 1 (strongly agree) to 5 (strongly disagree), the respondents centrally scored as follows on multi-item motivation constructs: on general motivation respondents disagreed that they only do their job so as to get paid at the end of the month. On overall the respondents agreed that they were very satisfied with their jobs. On organisational commitment, respondents disagreed that they felt very little commitment to the health facility they were based in. On conscientiousness, respondents strongly disagreed that they could not be relied on by their colleagues at work. On timeliness and attendance, respondents agreed that they were always punctual at coming to work, see Table   1.   Table 3. However, majority disagree that job refresher courses were provided on regular basis 119 (50.2%) and in the last 6 months their supervisors discussed their career development prospects with them 153 (64.6%), see Table 3.

Influence of training on performance:
Majority of the respondents agree that the work-related training they received made them make choices consistent with goals assigned to them 109 (56.2%), perform tasks assigned in good speed 93 (47.9%), perform duties assigned accurately 95 (49.0%) and help them go to the greatest extent to achieve goals assigned to them 98 (50.5%), see Table 4. Majority of the health service managers agreed that the work-related training provided made health workers make choices consistent with goals assigned to them 13 (61.9%), perform tasks assigned in good speed 13 (61.9%), perform duties assigned accurately 10 (47.6%) and help them go to the greatest extent to achieve goals assigned to them 11 (52.4%), see Table 5.

Discussion
This study was undertaken to determine the influence of training on motivated health workforce in Narok County. Overall, there was an average motivation level among health workers in Narok County at their current institution, sub-county and county. These motivation levels were lower as compared to motivation of health workers in Ghana where researchers reported that health workers achieved an overall motivation mean score of 3.65 (out of 5) translating to 7.3 out of 10 [13]. Findings from a study in Zambia reported as high as 60-74% motivation level of health workers in three study districts [14]. Similar low levels of health worker motivation was reported in public health facilities in Thika District, where the results indicated that majority of health workers were demotivated with respect to satisfaction of needs factors and job enrichment factors [15]. Similar findings have also been made in both Kenya and Benin among health workers where it was found that approximately 55% of the respondents did not rate their willingness to do a good job, according to organizational objectives as "rather good", "high" or "very high" [4]. While measuring motivation using multiple questions on constructs relating to motivation, findings were similar to those made in District hospitals in Kenya where studies reported that the majority of respondents strongly agreed to be hard workers and disagreed that they were often absent from work with many participants describing themselves as demotivated [16]. Similar findings were also made in three districts in Zambia where it was found out that in overall the health workers agreed that they were satisfied with their jobs and were committed to their organization while conscientiousness and timeliness and attendance had the highest scores [14].
These results show that there are wide variations in the general motivation of the health workers across health systems settings. to the affective and normative components of commitment [25].
Findings agree with a study conducted in Malaysia which indicated that accessibility and support to training, coupled with the incentive to gain knowledge, training setting and apparent benefits of training were all interrelated with the affective commitment, normative commitment and overall organizational commitment. Similarly, the location of training and the alleged training benefits showed an association with continuance commitment, however there was no association between training availability, support to training and motivation to learn with continuance commitment [26]. Achieving a competitive advantage within the health industry requires strategic HRM that will help align health workers' activities to the direction, purpose and objectives of the health care system [27]. This study outlined one broad HRM intervention i.e. training and its findings suggested a positive link between training and motivated health workforce from a different angle. The findings also suggested variations depending on different health system environments and level of implementation of training intervention. Training is one of the interventions recommended by the World Health Organization as critical to enhancing health worker motivation [14] and therefore Narok county health system should continuously assess its level of implementation to enhance and exploit the benefits of this relationship.
This study however had some potential limitations which may have affected the results. The study was carried out in two sub-counties in the county. It cannot be assumed that health workers in the other sub counties share similar views. Therefore, the results may not be generalized to the entire county and this is considered a limitation of the present study. The self-administered structured questionnaire used in data collection present a likelihood of respondents rating high on their responses which is an activity that is hard to control and this could have an influence on the results.
The studied population comprised of health workers in public health institutions and this may have missed out an interesting analytical angle had the study included health workers from private institutions.
Based on the results of the study, training is already in place and has been shown to enhance health worker's motivation and thus improving their performance. There is need for the health service managers at the county to strengthen health workers' training by ensuring trainings are more regular and involve them in discussing their career development prospects. Future studies should include health workers from private institutions in order to incorporate their views in order to adequately inform future interventions and other sub counties in the entire county of Narok should also be included.

Conclusion
Although results pointed out an average level of motivation among health workers in Narok County, the findings also indicated that  Training is known to be essential in equipping a workforce with the right skills, knowledge and capability to maximize performance.
What this study adds  There was an average level of motivation among health workers in Narok County.
 On-job training had been offered to health workers in Narok County and had an impact of motivating the workforce as well as enhancing their performance.
 There was a relationship between training and motivated health workforce in Narok County as training significantly predicted general motivation, job satisfaction, intrinsic job satisfaction and organizational commitment.

Competing interests
The authors declare no competing interests.