Staff Shortages Hinder Patient Care

Addressing the human resource needs of a Kenyan hospital

Even before the ARV targets had been introduced, there were not enough nurses to provide the quality of care the Director aspired to. The patients had to wait a long time for basic care, and by the time the overworked nurses finally came to the bedside, they were rushed and exhausted. The Director understood why the patients felt neglected and the staff demoralized.

Hiring new staff was not an option. A donor-imposed hiring freeze made it impossible to employ any new staff—not just nurses, but other essential employees as well. Even if the hiring freeze had been lifted, the Director would not have been able to hire the nurses she needed. The authority for hiring rested with the Public Service Commission and involved a complicated bureaucratic process that could take as long as a year for any new staff hire.

She might have tried to circumvent the freeze by attracting staff transfers from other areas of the country, but this was unrealistic because she lacked the funds to pay additional salaries. And even if funds had been available, few nurses would have chosen to transfer to her hospital because her region was widely known to have inadequate training opportunities, and little chance for career advancement. In fact, this situation was driving many of her own staff to seek better positions elsewhere.

For the Executive Director, the ARV treatment policy simply compounded what was already a discouraging situation, making it imperative that these human resource issues be addressed. Working with Management Sciences for Health (MSH) and Family Health International (FHI), the Director and members of the hospital’s management team met to consider the reasons for low staff morale and high turnover and to seek options for immediate action. The MSH and FHI consultants also conducted many interviews with staff at all levels, ranging from physicians and senior nurses to people who provided logistical and administrative support.

To begin, the team explored the factors that were affecting staff shortages at the hospital. They identified leadership as the first factor and agreed that the Executive Director needed to play a new leadership role, advocating with the Government to attempt to lift or modify the hiring freeze, at least in facilities designated as ARV treatment sites.

The assessment revealed a host of issues in regard to the second factor: human resource management.

  • There was great concern about inequities in promotion and salary increases; some staff members had been twice upgraded in the recent past, while others in similar positions stayed at the same grade level. Further, informants described what they viewed as partiality in the allocation of allowances and training opportunities.
  • Although a performance appraisal system was in place, it was used inconsistently.
  • Many staff did not have clear job descriptions, a lack that skewed appraisals and reduced the probability of promotion.
  • Staff members reported that frontline workers such as nurses, pharmacists, and laboratory technologists were often burdened with logistical and administrative tasks that caused them to spend a significant amount of time outside the wards where the core of their work should have taken place.

The management team used the findings from the assessment to make several recommendations. The key recommendation was to appoint a Human Resource Management Director who would be responsible for addressing staff inequities in salary and allowances, improving the timeliness of deserved promotions, and developing a system to quickly train existing staff to administer ARV treatment. The HRM Director would also introduce a package of non-monetary incentives and rewards, and work with training institutions to bring much needed career development opportunities to the staff.

This new appointment would relieve other management team members of major concerns that had been absorbing their time and attention. They could now focus on addressing the other problematic areas identified during the assessment: advocating for policy changes around the hiring freeze and the bureaucratic employment process.

FHI agreed to hire and pay the salary of the HRM Director until the hospital could do this on their own. MSH worked with the Executive Director to develop a job description for this position and agreed to provide technical assistance as the new HRM Director took on these much needed responsibilities.