POOR WORK ENVIRONMENT: A BARRIER TO EFFICIENCY IN HEALTHCARE DELIVERY SERVICES (A STUDY CONDUCTED AT FEDERAL MEDICAL CENTRE, OWO, ONDO STATE,

Efficiency in services is subject to adequate work environment which can be described as the surrounding conditions in which an employee operates. This study explored the knowledge, assessed the perception of health care givers about their work environment and assessed the barriers to efficiency of health care service delivery in Federal Medical Centre, Owo. A descriptive cross-sectional study was conducted among 284 health workers comprising of 171 nurses, 107 doctors and 6 community health and extension workers which was selected using multi stage sampling technique. Data was analyzed using STATA (SE 12.0) whereby frequency tables were run, mean and standard deviation was calculated. Results showed that majority (97.5%) of the workers had good knowledge of what constitutes a desirable work environment. All (100%) the workers had positive perception of a good work environment. And factors identified to be responsible for affecting conducive work environment which in turn affects workers’ productivity include lack of equity and fairness, poor communication system, occupational hazards and high workload leading to burn out, lack of motivation from boss, non availability of drugs to treat patients, lack of appropriate equipments, lack of autonomy, lack of in-service training, insufficient basic amenities for day-to-day job performances and lack of team spirit. The study concluded that productivity in workers and efficiency in health care delivery services can be hampered by factors we some time overlook in work places.

Efficiency in services is subject to adequate work environment which can be described as the surrounding conditions in which an employee operates. This study explored the knowledge, assessed the perception of health care givers about their work environment and assessed the barriers to efficiency of health care service delivery in Federal Medical Centre, Owo. A descriptive cross-sectional study was conducted among 284 health workers comprising of 171 nurses, 107 doctors and 6 community health and extension workers which was selected using multi stage sampling technique. Data was analyzed using STATA (SE 12.0) whereby frequency tables were run, mean and standard deviation was calculated. Results showed that majority (97.5%) of the workers had good knowledge of what constitutes a desirable work environment. All (100%) the workers had positive perception of a good work environment. And factors identified to be responsible for affecting conducive work environment which in turn affects workers' productivity include lack of equity and fairness, poor communication system, occupational hazards and high workload leading to burn out, lack of motivation from boss, non availability of drugs to treat patients, lack of appropriate equipments, lack of autonomy, lack of in-service training, insufficient basic amenities for day-to-day job performances and lack of team spirit. The study concluded that productivity in workers and efficiency in health care delivery services can be hampered by factors we some time overlook in work places.

…………………………………………………………………………………………………….... Introduction:-
Work environment can be described as the physical geographical location, immediate surroundings as well as factors such as work processes and physical factors like quality of the air, noise level and employment benefits (Business Dictionary, 2018). The work environment can also involve the social interactions at the work place which could make it conducive or hostile. Hostile work environment exists when someone's behavior within a work place creates an environment that is difficult for another person to work effectively in. It could be from colleagues or from the authority in charge (McGraw-Hill, 2010). Work environment can also refer to resources in place to work with such as manpower, equipments, funds, physical conditions such as temperature, illumination, noise (Helmrich, 2015). David (2016) discussed that desirable work environment should be accommodating and work-friendly.
Quality in any service is never a result of chance; it's always an outcome of calculated efforts. Despite rise in establishment of health care institutions, it is seen that efficiency in care service deliveries is going dim. It is relatively agreed that poor health care provider performance in low and middle income countries is basically increased by shortage in manpower and changes in social, economic and technological conditions. These changes pose major challenges to service care delivery. To meet the increased expectation of service delivery, health workers must focus on desirable goal of their work and articulate their role in terms of the value they create. Hence they must know how to offer the best of their abilities. This is a reality if work environment is conducive. Ajala (2012) quoted Bruce (2008) in his work to say that a study showed that workplace distractions reduce employee productivity by as much as 40%, and increase mistakes by 27%. Sources of distractions include poor lightening, poor ventilation (Moloney 2011).
In the U.S, a study conducted on "Hospital staffing, Organization and Quality of Care" revealed that adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burn out and ultimately to improving the nurse retention problem in hospital settings (Aiken, Clarke and Douglas, 2002). This lay emphasis on the fact that adequate human resources are paramount to efficiency in health care delivery.
Friction among healthcare givers especially doctors and nurses affects trust, job satisfaction and perceived quality of patient care (Heather, Shamian and Thomson, 2001). Asigele (2012), also in his work reported that to improve the performance of health care, supportive working environment is required. This is more than just having adequate equipments and supplies. It includes systems' processes, such as decision making with information exchange processes and capacity issues such as workload, support services and infrastructure. This supportive work environment could be in the form of office design, ventilation, lighting and other basic amenities. It was reported in the work of Prakash and Mohan (2015) that 84% of employees felt the location and office structure of where they work were not good enough. 74% felt noise distraction is a problem. Only 94% supported that other amenities such as lights, toilets, furniture colour were satisfactory. It was concluded in their work that undoubtedly, the physical environment would contribute much for better performance and productivity of employees if properly addressed. It also reported that the social environment of a particular workplace indicated that 92% of employees felt team spirit will make large impact on performance, above 80% believe that encouragement from boss and easy accessibility to managers when required will make work easier. In Nigeria, a study conducted to assess how nurse-doctor relationship affects productivity revealed that working relationship between doctors and nurses need to be improved so as to increase job satisfaction and on the long run, improve the efficiency of health care delivery (Ogbimi and Adebamowo, 2006) Ensuring that health and welfare services are of high quality, available and effective, made accessible and affordable, delivered by a concrete and sustainable national health and local welfare system that encourages immediate action to the needs of the people is of high importance but this cannot be achieved if the work environment is not accommodative.

Methods:-
The study employed a descriptive cross sectional design and was conducted in Federal Medical Centre, Owo, Ondo State, Nigeria. A Federal Government facility located within Owo/Ose constituency. The study was conducted among the core health care providers: nurses, doctors and community health officers. The total population of nurses before sample determination is 367 while doctors are 230 and community health and extension workers (CHEW) are 13. This brings total number to 610 as at the time of conducting the study.

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Sample size was calculated to be 284 and sample was selected using multi stage sampling method to choose samples for nurses, doctors and community health and Extension Workers (CHEW). In all, sample size of 171 was for nurses, 107 for doctors and 6 for CHEW.
Inclusion and Exclusion criteria are health care workers among nurses, doctors and Chew who gave consents, which have spent at least a year in the institution and health care workers among nurses, doctors and Chew who do not give consent, that are less than a year in the institution and that are under disciplinary action(s) respectively.
The study scope covered exploration of the knowledge of organization culture and work environment of the respondents, assessment of the perception of a good work environment of the respondents and described the factors that causes halt to efficiency in health care delivery services. The principal researcher and four research assistants administered the questionnaires (tool employed in the study) and gathered data over a period of two months. The research questionnaire used to get the necessary information is a structured self administered one. After completion of the field work, questionnaires were numbered; data were entered and analyzed using STATA (SE 12.0). Frequency tables were run, mean and standard deviation calculated where necessary, knowledge and perception of the respondents was analyzed. Factors that serve as barriers to efficiency in health care delivery services were identified.  Table I shows that above average (59.9%) were female. Respondents within the age group of 31-40 years had the highest percentage (48.9%). Out of the respondents, the profession that has the highest (60.2%) member is nursing. Most (71.1%) of the respondents had work experience of between 1-10 years while most (77.8%) had first degree as the highest educational level.

Results:-
483   Table III shows that most (83.4%) of the respondents said equity and fairness is absent in their institution. Half (50.3%) of the respondents agree that their work environment is free from noise. Above average (56.0%) responded that effective communication system is absent in their place of work. Above average (59.9%) responded that their 484 work environment is not free from occupational hazards. Most (86.2%) of the respondents responded that their daily work load is too much.  Table IV shows most (60.6%) responded that there is no motivation from their boss when a job is being done. With respect to equipping the pharmacy with drugs, above average (57.4%) responded that this is not so. Majority (79.2%) responded that equipments are not readily available to work with. Most (66.9%) responded that autonomy is not allowed in their profession. Majority (71.1%) said that in-service training is not done regularly to update staff knowledge and skills. Most (70.8%) of the respondents said that basic amenities for day-to-day job performance are not readily available in their institution. Most (64.8%) responded that there is no strong team spirit among members of staff.

Discussion:-
Demographic profile's review of relevant literature revealed that in accordance with this study's result, age range of most work forces is between 25-40 years. Educationally, people are getting more enlightened; first degree has the highest record. Work experience ranges between 1-10 years as evidenced by the work of Ali , Abdiaziz A and Abdiaqani A (2013); in their demographic analysis, age range of 25-40 years had highest (48%) rate, first degree had highest rate of 34.7% and work experience of 5-10 years had rate of 44.7%. In contrary to this study's results, which showed above average (59.9%) were females, their study revealed that males have highest rate (95.3%) at workplaces. Differences in culture and socio-economic factors might account for this.
From the study, it is revealed that nearly all (97.5%) the respondents have good knowledge of what constitute desirable work environment and culture. All (100%) of them have positive perception of what an ideal work 485 environment should be. This include that work environment is conducive when it makes assignments easily achievable. This corresponds with the works of Albaqami (2015) and Shikdar (2004) where they affirm that an effective workplace is an environment where results can be achieved as expected by management if appropriately worked at. Also, work environment is "the sum of the interrelationship that exists within the employees and the employees with the environment in which the employees work" (Akinyele, 2010) and McGraw-Hill (2010) where he said work environment can also involve the social interactions at the work place which could make it conducive or hostile. Working conditions refer to the work environment and aspects of an employees' term and conditions of employment. This is in line with the work of Ali et al (2013). Wherein they weighed all definitions of work environment and then eventually arrived at the above. Working conditions are created by the interaction of employee with their organizational climate. Ali et al (2013) quoted Gerber et al (1998) in their work to agree with the fact that "working conditions are created by the interaction of employee with their organizational climate and includes psychological as well as physical working conditions''.
An ideal work environment help to create a sense of worth among employees; this is in agreement with Dawn (2006) who presented that "praise and motivation at work places is often forgotten or ignored and this if done tend to give an individual worker a sense of worth in relation to the actual work that they have done for the company, praise and recognition have been shown to dramatically increase productivity". In-service training for members of staff of an organization is perceived to be a good organization culture this is in line with Poh (2013). He reported that a positive work environment has to be training & development-focused. A good work environment is perceived to have good personnel-patient ratio as it reduces burden of work load. The work of Aiken et al (2002) supports this. It examined nurse staffing in hospitals and came to conclusion that "adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings". A good work environment should give recognition to achievements and constructive feedback. Poh (2013) submitted that there should be recognition for hard work. Graham (2014) is also in support of this. He said keeping employees happy and productive requires frequent and open communication, regular recognition of achievements and constructive feedback. Perceived good work environment is one that has honesty, trust and fairness as it's most valued attributes. This is in line with Graham (2014) submission which stated that 90% of workers believe that the most valued attributes in workplaces are honesty, trust and fairness; trust can be fostered actively by proactively building interpersonal trust and communicating with predictability. An ideal work environment is perceived to be free from harassment. This is seen as a good thing but most often than none, harassment at work is a reality. According to Einarsen (2000) harassment is experienced when there is hostility at work environment. This hostility can be in the form of insulting remarks, persistent criticism, physical abuse and threat.
All (100%) the respondents agreed that equity and fairness is needed for any organization to move forward; this is in accordance with the work of Dawn (2006), he believed that a key motivation for employees in a work environment is that each employee is treated fairly no matter what level of input a particular worker has in relation to the work processes as a whole. But majority (83.4%) of the respondents reported that equity and fairness is absent in their institution. Almost all (95.1%) the respondent said that a work environment should be noise free to avoid distractions; this is in line with the work of Prakash and Mohan (2015). It was reported that 84% of employees felt the location and office structure of where they work were not good enough and 74% felt noise distraction is a problem hence should be avoided. In this study, it was reported to be well addressed in the institution as above average (50.3%) affirm that their work environment is noise free. All (100%) the respondents said that an effective communication system is needed for an organization to run smoothly. This is in line with the work of Dawn (2006). He said communication is a must in a work place. Good communication skills are imperative for outstanding performance and career management. A good number (56.0%) of the respondents said this is not present in their institution. Majority (92.6%) affirm that a good work environment should be free from occupational hazards. Quite a number (59.9%) said this is not so in their institution. Occupational safety in the hospital setting is paramount as it helps to improve patient safety and staff welfare (American Association of Critical care Nurses, 2006). Nearly all (99.6%) the respondents opined that the daily work load of an organization should be one that is within his capacity/ability. Most (86.2%) of the respondents reported that this is not applicable in their institution. Stavroula, Griffiths and Cox (2004) in their book opined that pressure of work at the workplace is unavoidable due to the demands of the contemporary work environment. Sources of increased workload include poor staffing, lack of equipment. According to Aiken et al (2002), adequate nurse staffing and organizational/managerial support for nursing are key to improving diminishing nurse job dissatisfaction and burnout.
486 Most (60.6%) of the respondents claim that there is no motivation from their boss when job is being done, Jones (2010), opined that workers need to be motivated, encouraged, rewarded and recognized; if not they begin to get weighed down. Above average (57.4%) reported that drugs are not readily available in the pharmacy for patients; this is a major setback for effective service delivery. In the study of Asigele (2012), it was revealed that non availability of drugs significantly affects health worker performance. Majority (79.2%) reported that equipments are not readily available to work with. This is a major setback to effective service delivery, in line with the work of Ogundele and Olafimihan (2009). They reported that non availability of equipments and inadequate facilities are contributing factors to substandard care. Most (66.9%) of the respondents reported that autonomy is not allowed in their profession. The acceptance of autonomy at workplaces gives enhanced bottom-up planning approach, increases health workers' accountability and reduces bureaucratic procedures in decision making (Frumence, Nyamhanga, Mwangu and Hurtig, 2013). Majority (71.1%) of the respondents reported that in-service training is not done regularly to update their knowledge and skills. In-service training of workers has been and will remain an important investment in developing and maintaining essential competencies needed for optimal public health in all global service settings (Bluestone, Johnson et al, 2013). Majority (70.8%) reported that basic amenities for day-to-day job performance are not readily available in their institution. Ogundele et al (2009) reported that lack of basic amenities like water, steam, electricity in our hospitals has hindered the provision of quality health care. Most (64.8%) of the respondents said that there is no strong team spirit among the workers. Institute of Medicine (IOM) reports have emphasized the importance of teamwork in improving efficiency and quality in hospitals (Buerhaus, Donelan et al, 2007).

Conclusion:-
Quality in healthcare services should never be assumed will occur by accident, it should be worked towards. The study showed that efficiency in healthcare service delivery can be hampered by poor work environment which could come in form of lack of equity and fairness towards personnel, poor communication system, presence of occupational hazard, workload, lack of motivation, non-availability of equipments and basic amenities, lack of professional autonomy, poor in-service training and poor team spirit among workers.