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Health care workers (HCWs) are people whose job it is to protect and improve the health of the people. The World Health Organization defines Health workers to be all people engaged in actions whose primary intent is to enhance health [1]. These include Medical Doctors, Nurses, Pharmacists, Dieticians, Physiotherapists, Laboratory Scientists, and Dentists and so on. Human resources represent “the most expensive of three principal health system inputs as they consume almost 60% of the total budget, the other two being physical capital and consumables” [2].

The code of professional conduct and ethics guide Health workers in their day to day practice and helps them understand their professional responsibilities in caring for patients in a safe, ethical and effective way. However, motivation of health workers is critical for optimum health service delivery [3]. Motivation is an individual's degree of willingness to exert and maintain an effort towards organized goals [1]. Work motivation can be affected by intrinsic and extrinsic factors. Intrinsic motivation can be shaped by people’s interest in the work itself while extrinsic motivation can be shaped by features of policy making such as strong career development, an adequate compensation, adequate working and living conditions, career development, adequate new medical resources, recognition and appreciation [4]. Motivation is complex and multidimensional and therefore also defined as "the force within individual that influence or direct behaviour" [5] and is the “result of the interactions between individuals (internal psychological process), their work environment (a transactional process) and the fit between these interactions and the societal context” [6]. It is closely linked to job satisfaction which can be described as a optimistic feeling which comes from the evaluation one’s job and neither motivation nor job satisfaction is directly observable, but both are critical to the retention and performance of health workers [7].

Sub-Saharan Africa is coping with 24% of the world disease burden and also has a health system which is described as unresponsive, ineffective, inefficient and unsafe [1]. This can be attributed to poorly motivated workers which have been suggested to be a main determinant of quality health care service and has also been linked to the series of protest and strikes by doctors, nurses and allied health care workers in different teaching hospitals all over Nigeria [8]. These strikes have negatively impacted on the health system, leading to several unavoidable deaths, complications and capital flights as the wealthy seek health service abroad and furthermore, led to migration of HCWs to other countries [9]. With the challenges facing this sector, including rapid advancing technology, the re-structuring, the current events facing professionals in the health sector, and the dynamic customer needs, understanding the needs of the health worker becomes more essential than ever to promote a quality health service and to create a healthy environment both for the patient and the worker [10]. Although it has been accepted that the presence of highquality and motivated staff is essential for provision of quality healthcare, at the same time it has also been acknowledged that this is one of the most difficult inputs to assess and ensure [11]. Since the publication of the World Health Report in 2006, which stated that there was an urgent need for the global community to address the crisis in the global health workforce, particularly in sub-Saharan Africa, the international community, led by the World Health Organization (WHO), has organized several global forums on human resources for health [6].

Given these current challenges such as poor working conditions, personal safety concerns and inadequate equipment facing health care in developing countries such as Nigeria, job motivation could play a key role in productivity of human resources for health in these countries [12]. This study was aimed at the assessment of motivation in HCWs in a public tertiary hospital in Enugu state, Nigeria with hopes to help inform decision making in the area of strategic planning with regards to staff motivation in the country.

This study was a descriptive cross sectional study carried out among HCWs in a tertiary teaching hospital in Enugu state. Enugu state is located in the southeast geopolitical zone of Nigeria. Politically the state is divided into three senatorial zones and seventeen Local Government Areas (LGAs). It has a total population of 4,881,500 people within a total area of 7618 sq. km. The inhabitants are predominantly of Igbo ethnicity and Christians. The major occupation includes farming, trading and civil/public servants. A sample size of 356 was obtained using the sample size determination formula for cross-sectional descriptive studies [13] and a prevalence of 63.63%.

The study population consisted of hospital staff from the following departments: Nurses, Physiotherapists, Medical radiographers, Laboratory scientists, Dentists, Pharmacist and Doctors. The multistage sampling technique was used. Stage 1: There are two government owned tertiary hospitals in the State and using a simple random sampling method using balloting method, one was selected for the study. Stage 2: A list of the different cadre of staff was obtained from the personnel department and participants were proportionately selected via simple random sampling, using balloting method from all the above mentioned departments.

Data collection was carried out using a semi structured interviewer administered questionnaire. This was used to obtain data on sociodemographic variables, perception of health care workers about motivation, intrinsic forms of motivation practiced at the workplace, extrinsic forms of motivation practiced at the workplace and effects of lack of motivation. The questionnaire was validated by pretesting it in another second tertiary hospital in the state which was not included in the study and data was analyzed using the statistical package of the social sciences software (SPSS) version 22.

Ethical consideration

Ethical clearance was sought from the Health Research and Ethical Committee of University of Nigeria Teaching Hospital, Ituku-Ozalla. Permission was also sought from the hospital management of the selected facility. Verbal informed consent was obtained from the HCWs during which their cooperation were sought. Confidentiality was assured and maintained.

A total of 356 healthcare workers participated in the study of which 129(36.2%) of respondents were nurses, 132(37.1%) were medical doctors, 26(7.3% ) pharmacists, 40(11.2% ) medical laboratory scientists, 10(2.8%) physiotherapist and 19(5.3%) medical radiographers. Majority were female 224 (62.9%) while 132(37.1%) were males. The mean age of respondents was 33+7.9 years (Table 1).

Table 1: Socio-demographic characteristics of respondents.

In HCWs perception about the concept of motivation, most of the respondents 330(92.7%) felt that motivation of an individual was a degree of willingness to exert a goal, 347(97.4%) believed that motivation was important in healthcare delivery service, and 334(93.8%) agreed that everyone was unique and requires different motivational factors. However, very few 26(7.3%) felt motivation of workers was being taken seriously by the hospital management (Table 2).

Table 2: Perception Of Health care workers about motivation.

Intrinsic forms of motivation which respondents strongly agreed they experienced in their work place was appreciation by superiors 50(14.0%), sense of achievement with completion of difficult tasks 63(17.7%), advancement in career 53(14.9%) and sponsorship for training 72(20.2%) (Table 3).

Table 3: Intrinsic forms of motivation practiced at the workplace.

While, extrinsic forms of motivation which respondents strongly agreed to experience were prompt payment of salaries 66(18.8%), free accommodation 89(25.3%), good working conditions 86(24.4%), job security 33(9.4%) and satisfaction with hospital policies 49(13.7%) (Table 4).

Table 4: Extrinsic forms of motivation practiced in the workplace.

When motivational levels were ascertained from respondents, 61 participants (17.1%) felt they had a very low motivational level, 135(37.9 %) had low motivational levels, 48(13.4%) were undecided about their motivational level, 92 participant (25.8%) felt they had a good motivational level and, 20 participants (5.6%) felt their motivational level was very high.

75(21.1%) of the HCWs believed that the most common effect of lack of motivation was an intent to migrate and appropriate remuneration 313(87.9%) was the best strategy to improve motivation of HCWs while, a well-defined career 280(78.7%), challenging job 188(52.8%) and good leadership and unity among colleagues 158(44.4%) were other strategies preferred (Table 5).

Table 5: Effect of lack of motivation.

Motivation is closely linked to job satisfaction and retention [14]. Human resources for health are a vital component of an effective health care system and as many countries especially developing countries experience shortage of healthcare workers, this leads to serious consequences for the health of the people. Universal access to good quality care and optimal patient safety is the goal of health systems and governments all over the world. Most developed countries have made great strides towards fulfilling this goal, but many developing countries in Africa lag behind due to financial, material and human resource constraints [15]. Keeping health workers satisfied and motivated helps the entire health system work smoothly [16].

The notion that different individuals are motivated by different factors was recognized by most of the health workers to be true. This could be explained by individual uniqueness where the best motivation for an individual may not be the same for another. In this situation one ’ s beliefs and way of life in general becomes an important determinant.

Generally, it has been shown that “employees want to perform their jobs well, to increase their capacity and opportunity to add value, and be part of an effective and humane organization” [17]. Therefore, motivational factors, whether intrinsic or extrinsic have roles to play in achieving this. Most of the HCWs in this study revealed that many intrinsic and extrinsic forms of motivation were lacking in their workplace. Low morale among any workforce can reduce the quality of service provided and drive workers away from the occupation and even from their country and this can be worrisome especially in the health sector. The quality of health services, their efficacy, efficiency and accessibility depend on the performance of health professionals delivering these services, so it is important to consider staff motivation and development an integral issue in health policy [18].

Research has shown HCWs perceived appreciation as one of the most effective factors in work motivation [19]. However, in this study, the experience of this was found to be low as were other possible motivational factors and may be because, some superiors may assume that to carry out one’s duty is mandatory after all, the worker is remunerated to do so.

Most of the respondents suggested that appropriate remunerations was the best strategy to motivate workers this is a similar finding in other African countries [20,21] but differed in China where research conducted showed that the most important factors for performance improvement of health care professionals are the opportunities for professional development, training and skill enhancement and good working environment and conditions [22] leading to belief that motivational factors may be country or regional specific. Furthermore, financial incentives alone have also been found not to be enough solely to motivate health workers so, financial incentives should be integrated with other incentives [23]. Research has also found that human resource development is gradually being recognized as crucial to future reforms and the formulation of health policy [10] and motivation appears to differ between public and private health care facilities as workers in private facilities are perceived to have better working conditions than workers in public facilities [15].

The African continent is currently facing a severe human resource crisis. In the health sector in the recent years, there have been a large number of health workers migration to more developed countries [23]. The HCWs studied revealed that intent to migrate is one of the major effects of lack of motivation a similar study in Tanzania also found that a significant number of health care workers reported that they had considered resigning from the hospital, leaving rural areas for the urban or leaving the country altogether confirming earlier research that low motivation amongst workers is a major factor in migration of health staff [24,25]. Incessant strike action and absenteeism from work were also identified as consequences of lack of motivation of health workers.

Nowadays, the task of motivation in the health care sector is complicated by the nature of the relationship between those using the system and the system itself (physicians, patients, and hospitals) and exacerbated by the management of the heterogeneity of the workforce [26]. The health industry is also labor intensive under increased societal demand for quality and effective healthcare services and it has become a challenge for hospital managements to motivate employees and at the same time fulfill the expectations of patients. Research has as well highlighted the importance of effective human resource policies for improving the performance of the health system [2].

With these low experiences of both intrinsic and extrinsic motivational factors in the workplace, it is not surprising that most HCWs perceived themselves as having low motivational levels and unfortunately, most felt that the means to motivate them are not taken seriously by the hospital management and it is also generally presumed that this important attribute of the workplace in public hospitals is not usually given adequate attention as desired [27]. A study on motivation of HCWs in Iran highlighted that the most important motivating factor for health workers was good management showing that health workers have positive attitudes towards the importance of management practices in the organization [12] also, In a systematic review of motivation and retention of health workers in developing countries, the important role of management as a motivational factor was further highlighted [28].

The information from this study leads to the understanding that employers need to explore intrinsic and extrinsic motivational options that are available within the health care system and apply them appropriately. The results of this study could be useful, especially in developing countries like Nigeria where health care human resource challenges continue to impede the provision of quality health care services and lead to migration of healthcare workers.

Policy strategies to strengthen human resources for health in Nigeria should focus on financial remunerations, working conditions, facility infrastructure, management, and workforce camaraderie. There is also need to initiate mechanisms to improve communication amongst the various cadres of workers and between management and workers and incorporate career development programmes into hospital activities. These programmes should be geared towards projecting what the career path looks for various cadres of HCWs so achievable goals can be set.

This study was carried out in only one tertiary hospital and so findings may not be a true representative of the perception of all HCWs in tertiary hospitals in Nigeria.