Factors Affecting the Performance of Professional Nurses in Namibia Affiliations: Problem Statement Definition of Key Concepts Significance of the Study Research Method and Design Population and Sampling Data Collection Method Ethical Considerations Validity and Reliability

Background: Professional nurses play a vital role in the provision of health care globally. The performance of health care workers, including professional nurses, link closely to the productivity and quality of care provision within health care organisations. It was important to identify factors influencing the performance of professional nurses if the quality of health care delivery was to improved. Objectives: The aim of the present study was to identify factors affecting the performance of professional nurses in Namibia. Method: A quantitative, descriptive survey was used to collect data by means of a questionnaire. A random sample of 180 professional nurses was selected from six hospitals in three regions of Namibia. Results: Factors affecting the performance of nurses negatively were identified such as: lack of recognition of employees who are performing well, quality performance outcomes and an absence of a formal performance appraisal system and poor working conditions. Various factors contribute to both the positive and negative performance of professional nurses in Namibia. Strategies were developed for addressing the negative factors that could positively affect the performance of professional nurses in Namibia. Conclusions: This study emphasises the importance of developing strategies to promote the performance of nurses; build knowledge and expertise; develop mechanisms for improving the performance of nurses; expand leadership and management capacity; and generate information and knowledge through research. Introduction Improving the productivity and performance of health care workers in order to enhance efficiency in health interventions, is a major challenge for African countries. Human resources for health (clinical and non-clinical) staff are paramount as staff is the most important asset of health systems. Performance of health care organisations depends on the knowledge, skills and motivation of individual employees. Employers should provide working conditions which support the performance of employees. Health care workers are not producing the desired output in terms of health interventions, which is a concern for the World Health Organization (WHO) and policy-and decision-makers (High Level Forum 2004:1; World Bank 2000:5). Insufficient health personnel, in terms of numbers and performance level, are regarded as a major constraint in achieving the Millennium Development Goals (MDGs) for reducing poverty and diseases in many African countries. Proposed remedial actions include improving motivation, retention, productivity and the performance of health care workers, and mobilising unemployed trained staff, or those working in other areas, to return to The quality, efficiency and equity of services depend on the availability of skilled, competent …


Introduction
Improving the productivity and performance of health care workers in order to enhance efficiency in health interventions, is a major challenge for African countries.Human resources for health (clinical and non-clinical) staff are paramount as staff is the most important asset of health systems.Performance of health care organisations depends on the knowledge, skills and motivation of individual employees.Employers should provide working conditions which support the performance of employees.
Health care workers are not producing the desired output in terms of health interventions, which is a concern for the World Health Organization (WHO) and policy-and decision-makers (High Level Forum 2004:1;World Bank 2000:5).Insufficient health personnel, in terms of numbers and performance level, are regarded as a major constraint in achieving the Millennium Development Goals (MDGs) for reducing poverty and diseases in many African countries.Proposed remedial actions include improving motivation, retention, productivity and the performance of health care workers, and mobilising unemployed trained staff, or those working in other areas, to return to the health sector (High Level Forum 2004:7;Stilwell 2001:2).

Problem statement
The quality, efficiency and equity of services depend on the availability of skilled, competent health professionals when and where they are needed.Health care workers need appropriate training to deliver the required standard of services.Interviews with nurses in Namibia indicated that nurses, comprising the backbone of health services, are overworked, demoralised, showing signs of burnout and complained about no recognition for their contributions (Awases et al. 2004:53;WHO 2003:18).Issues of performance and factors affecting performance are not adequately addressed in Namibia.Nurses have a major role to play in providing timely, quality health services as nurses and midwives comprise 80% of Namibia's health workforce (WHO 2011 accessed 16/12/2012).

Background
Namibia, with a per capita income of $6250 in 2008, exceeds the regional average of $2274, but is below the global average of $10 307 (WHOSIS), with great inequality in the distribution of income.The economy depends mainly on mining such as; diamonds, uranium, gold, silver and copper (Namibia Government).
Identified health challenges and needs include timely, efficient health care services; poor human resource management; poor performance of health personnel resulting in poor quality of services; negative attitudes and low motivation of health care workers; and a general feeling of despondency amongst health care workers due to limited opportunities for career advancement and performance reward systems (WHO 2000:1).The importance of performance management in the health workforce is regarded as 'essential to improving efficiency, productivity and quality of care' (South Africa 2011).
There is presently no performance appraisal system in place for health services staff in Namibia, because the previous system was abandoned in 1998 (McCourt & Awases 2005:7).Though the discontinued performance appraisal system was used ad-hoc in various disciplines in the Ministry of Health.Employers are supposed to ensure performance of a high standard by employees, or put measures in place to detect and rectify poor performance of first-line health care workers who are in contact with clients, patients and the community.

Purpose of the study
The purpose of the study was to identify and describe variables affecting the performance of professional nurses in Namibia.

Objective
The objective of this study was to determine factors which positively and negatively affect the performance of professional nurses in Namibia.

Definition of key concepts
Performance: Perform means 'to carry out, accomplish or fulfil an action or task'.It also means 'work, function, or to do something to a specific standard'.Performance is 'an action or process of performing a task or function' (Oxford Concise Dictionary 1999:1060).Important variables to be kept in mind are; function, work, action, task, process and specific standard.Performance is the actual conducting of activities to meet responsibilities according to standards.It is an indication of what is done and how well it is carried out (Winch, Bhattacharrya, Debay, Sariot, Bertoli & Morrow 2003:2).
Performance appraisal is the 'process of observing and evaluating an employee's performance, recording the assessment, and providing feedback to the employee'.(Muller, Bezuidenhout & Jooste 2011:564.)Performance management in the context of staff management it 'is about helping people to work more effectively by improving individual and team performance, increasing the overall productivity of an agency'.(PSMPC 2000:1) Professional nurse: A person registered with the nurse regulatory and registering authority of their country.Professional nurses are trained at higher education level with the training period between 3 and 4 years.Professional nurses, also called registered nurses, working in clinical nursing services and educational institutions.
Skill is the ability to perform a task, or a group of tasks, which often requires the use of motor functions, but also require specific knowledge and skills.
Work environment Characteristics of the environment in which a person is expected to work.The work environment includes physical and social environment, conditions of employment and benefits.

Significance of the study
The findings of this study identified factors that affect the performance of professional nurses in Namibia positively or negatively.

Research method and design
A quantitative approach was followed.A non-experimental descriptive survey, gathering data by means of a questionnaire was followed to collect data from professional nurses about factors that could influence their performance positively and negatively.

Population and sampling
The population for this study consisted of all professional nurses in Namibia.The target population for this study constituted professional nurses in public and private hospitals within the boundaries of the Oshana, Otjozondjupa and Khomas regions of Namibia.
The population consisted of 770 professional nurses, from which 180 (23.4%) were randomly selected from a numbered staff list (excluding those on leave).

Data collection method
A self-administered questionnaire was designed in line with the objective and literature review, consisting of openand closed-ended questions.Respondents indicated their responses on a Likert scale for agreement levels (1 = strongly disagree -5 = strongly agree), or from very poor to excellent, to measure their opinions, reactions and attitudes in relation to given statements (Polit & Beck 2012:301).The questionnaires, together with a return envelope, were delivered personally by the researcher to the nursing manager of each hospital.During these visits the aim, importance of the study and questionnaire return dates, were explained.Of the 180 questionnaires that were distributed, 147 were returned.

Data analysis
Descriptive statistics that include frequencies and percentages were used for analysis of data.For the open-ended questions, data were organised under thematic categories and used in the discussions to support results from the close-ended questions.The statistical analysis programme SPSS was used to analyse the data.

Ethical considerations
Permission to do the study was acquired from the Permanent Secretary, Ministry of Health and Social Services of Namibia, as well as the medical superintendents of the participating hospitals.
Respondents were informed about the objective of the study, their voluntary participation and their right to withdraw from the study at any time.Anonymity and confidentiality were ensured by providing self-addressed envelopes with all questionnaires, requesting respondents not to write their names on the questionnaires.

Validity and reliability
Reliability of the instrument was determined by means of the Cronbach's Alpha, testing the internal consistency of items.The reliability of most items was adequate, whilst a few items such as; interpersonal relations, performance, commitment and satisfaction recorded a reliability of below 0.60.
Content validity was achieved because a panel of experts composed of; experienced professional nurses, human resource managers, academics in nursing and a statistician, judged whether the instrument reflects the known content area.After proposing some changes, there was consensus amongst these experts that the instrument was valid for the study (Brink, Van der Walt & Van Rensburg 2006:160;De Vos, Strydom, Fouche & Delport 2005:161).The instrument was field tested prior to the use of the final document, after which the document was refined and some questions were rephrased.

Discussion of results
For the sake of the discussion, percentages of the positive values 'tend to agree and fully agree', 'strongly agree and agree' and 'good' and 'excellent' were combined.The same applies to the negative values.

Biographical information
Of the respondents 78.9% (n = 116) were between 30-49 years of age, 93.8% (n = 138) were females and 71.4% (n = 105) had diplomas in nursing and midwifery as their highest nursing qualifications.A third of the respondents (35.4%; n = 52) had worked as professional nurses for 11-15 years and only 8.2% (n = 12) of the respondents were working in private hospitals.

Knowledge and skills
The majority of respondents perceived their knowledge and skills to be satisfactory on a number of items listed.Nursing audit received the highest score (86.3%; n = 125), followed by planning of nursing care (85.4%; n = 123) and interpersonal relations (78.8%; n = 112).A third or less of the respondents rated themselves as average in providing in-service training (34.7%; n = 50), patient counselling (31.3%; n = 45), self-assessment with regard to performance outcomes (24.5%; n = 35), and quality improvement (21.9%; n = 32) (See Table 1).Roux and Halstead (2009:475) regard nurses as knowledge workers, 'taking information from many sources and combining it in meaningful ways'.These skills are essential for improving the quality of care, supervising students and providing in-service training to address the skills gap in the clinical wards.

Performance appraisal and utilisation thereof
More than a third (38.1%; n = 56) of the respondents indicated that their performance were not reviewed and 19.1% (n = 28) indicated that the reviews took place in an informal and ad hoc manner when there was a performance problem.Of the respondents 52.2% (n = 77) said the results of performance appraisals were not used, whilst 17.7% (n = 26) and 14.3% (n = 21) said that they were used for promotion and training respectively.Roussel and Swansburg (2009:553) indicated that monitoring of performance enhance commitment and productivity.Appraisals also motivate and re-enforces those who are performing well and should be seen as a continuous process.
Although 40.6% (n = 58) of the respondents agreed that expected performance standards were clearly understood, 28.5% (n = 41) disagreed.Sixty-one percent (n = 86) of the respondents disagreed that constructive feedback on appraisals was provided on a regular bases and 55.3% (n = 79) disagreed that feedback on how staff were performing, was provided throughout the year (See Table 2).
Some professional nurses were happy with their remuneration.However, 48.3% (n = 70) did not feel that hardworking nurses are recognised.Some of the participants reported their opinion relating to remuneration as follows on the relevant open-ended question: 'I reached my maximum salary scale and remained at the scale for that last 5 years and I will remain at the scale for the next 20 years, unless there is an increment for all civil servants … Remuneration does not compare well with other organisations.We are doing more work than others, but is paid less'.(Female, professional nurse, age unknown) More than half of the respondents 54.6% (n = 77) were dissatisfied with their fringe benefits and remarked that 'There are no other benefits, except for housing subsidy allowances … The benefits are not clearly explained to us'.
(Female, professional nurse, age unknown) The majority (75.9%; n = 110) disagreed that hardworking nurses were recognised, and 47.9% (n = 67) disagreed that opportunities existed for career advancement (See Table 3).This is substantiated by the following responses:  Cowen and Moorhead (2011:161) also acknowledged that 'salary and benefits were the main causes of the [nursing] shortage'.The lack of a good and fair performance appraisal can also be regarded as a source of dissatisfaction, causing them to resign.
The majority of respondents agreed that the work they are doing gives them a feeling of personal achievement (78.9%; n =116).They were less in agreement with the statements that they will receive a reasonable pension from the organisation on retirement (43.5%; n =64), and that they found their work rewarding (41.3%; n = 59).The majority (50.3%; n = 74) were of the opinion that their pay are not competitive with other similar organisations.

Staffing and work schedules
Some respondents disagreed with fairness of work schedules (43.8%; n = 63), whilst 34.7% (n = 50) agreed.Of the respondents 59.3% (n = 86) disagreed that sufficient staff is allocated to cover the workload and stated: 'Shortage of staff, especially with a huge workload much more than the available staff … Most nurses sometimes work beyond their scope of practice due to shortage of medical practitioners'.
(Female, professional nurse, age unknown) Letvak and Buck (2008:163) indicated that an increase in the workload resulted in increased absenteeism and a decrease in quality of care.The High-Level Forum on Health MDGs (2004:3) and Erasmus and Brevis (2005:54) confirm that staff shortages are constraints for delivering health care services.

Staff development
Staff development programmes in organisations are designed to ensure that staff knowledge and skills are developed, strengthened and kept up to standard, ensuring excellent care (Muller et al. 2011:366;Price 2000:348).
Respondents disagreed that opportunities for advancing in the organisation (45.8%; n = 66), continuing education (42.1%; n = 61), job specific refresher courses (48.2%; n = 67) and good leadership and management training (51.4%; n = 74) were available.The rest of the respondents either indicated that they were uncertain, or agree, with these statements.An even larger percentage (61.8%;n = 89) of respondents disagreed that incompetent nurses were identified and provided with the necessary support (See Table 4).
During the appraisal interview, the manager should establish deficiencies in the knowledge and skills of employees and address these through creating staff development opportunities (Muller et al. 2011:350).

Workspace and environment
More than a half of the respondents (57.5%; n = 81) disagreed with the availability of the necessary instruments, that the instruments were in working condition (56.7%; n = 81) and sufficient materials and supplies were available (61.8%; n = 89).Responses to open-ended questions on professional nurses' desired improvements included; 'maintaining of facilities and equipment', 'modern equipment needed' and 'speedy repair of equipment'.
Most respondents agreed that infection control guidelines were available (66.6%; n = 96), as well as antiseptic hand solutions for protection of staff and patients (62.5%; n = 90).
Half of the respondents 50% (n = 71) disagreed with the statement that the work environment was safe and hazard free, whilst 19% (n = 27) were uncertain and 31% (n = 44) agreed (See Table 5).N, Given as total number; n, Given as number.
The physical conditions were not conducive to work, constraining employees in providing quality care.This was confirmed by Cowen and Moorhead (2011:15) and Meessen, Kashala and Musango (2007:108) indicating that unavailability of equipment, searching for supplies and having to wait for medications are performance barriers.

Organisational mission and goals
Of the respondents 46.3% (n = 68) agreed that the organisation's mission was understood by everyone, whilst 70.8% (n = 104) agreed they understood what objectives had to be achieved and 51.7% (n = 76) knew how their work contributed to the organisation's mission.(See Table 6).Bennett and Franco (1999:4), Nickols (2003:2) and Roussel and Swansburg (2009:289) also concluded that employees should know the organisation's goals and mission, as well as their own objectives and expectations in order to contribute to the overall goals of the organisation.

Commitment and satisfaction
There seems to be a sense of professional pride and vocation as indicated by the following responses when respondents either agreed or strongly agreed that doing this job makes them feel good about themselves (78.6%; n =114), that they were proud to tell people they work for this organisation (65.8%; n = 96), that the organisation provided them with skills and knowledge that will benefit their future (56.5%; n = 83) (See Table 7).Ahmad and Oranye (2010:584) regard organisational commitment as 'essentially about [their] attitude and behaviour towards shared goals of a group or organization'.Committed nurses might feel that there are future advantages in working as nurses for the organisation.

Aspects related to leadership and management style
Most respondents trusted and respected their immediate supervisors (81%; n = 119), whilst 53.1% (n = 78) were of the opinion that their managers and/or supervisors inspired them to do their best, and 36.8%(n = 54) agreed that management always informed affected people about changes (See Table 8).Managers' leadership and management styles in the organisation have a significant effect on the performance outcomes of their subordinates.According to Booyens (2008:243) leadership competencies include 'the ability to build staff's capacity to perform at a high level through constructive feedback and development'.

Implications for nursing management
There were no official guidelines available to improve the performance of professional nurses in Namibia.The following strategies are proposed in the form of broad strategic actions to address the strengthening and performance of professional nurses: • Building knowledge and competencies through continued professional development, in-service training programmes and clinical specialisation.

Limitations of the study
• Some of the older Afrikaans speaking nurses might have encountered some language difficulties with the English terminology, as clarification was requested in Afrikaans about the meanings of some of the terms used in the questionnaire.• All aspects related to factors affecting performance of professional nurses might not have been dealt with during this study.However this study results and the instruments developed might serve as a baseline for further research addressing aspects overlooked during this study.• Due to the small number (8.2%; n =12) of respondents from private hospitals comparisons between public and private hospitals were abandoned.• To ask respondents to determine their own perceived knowledge and skills is not the best method to obtain the data.The researcher had, however, no other way to determine it as she could not observe each respondent to determine it.

Recommendations
This study provides valuable feedback about the factors affecting the performance of professional nurses in Namibia.
It is therefore recommended that the health services managers will implement the strategies developed above to improve the performance of the professional nurses employed in their institutions.
There is a gap in literature about performance management of health care workers in general and more specific professional nurses in Namibia and South Africa.Research in performance management is necessary to enhance the quality of health care delivery.

Conclusion
The purpose of the study was to identify and describe variables affecting the performance of professional nurses in Namibia.In this study the selected Namibian hospitals had deficiencies in managing human resources, implementing a performance appraisal system, staff and skills development and maintaining a conducive work environment.Regardless of the negative factors, the study affirmed nurses' commitment and professional pride, indicating that they were proud to be nurses despite all the problems constraining their work.

TABLE 1 :
Knowledge and skills.
N, Given as total number; n, Given as number.

TABLE 2 :
Performance appraisal and utilisation of results.
N, Given as total number; n, Given as number.

TABLE 3 :
Remuneration, benefits, reward and recognition.I am a registered nurse for 21 years and get the same salary as a person/registered with 5-10 years' experience … even if you study and have a degree you are just getting the same salary as the person who has only a general nursing diploma'.(Female,professional nurse, age unknown) N, Given as total number; n, Given as number.'
N, Given as total number; n, Given as number.

TABLE 5 :
Workspace and environment.

TABLE 6 :
Organisational mission and goals.
N, Given as total number; n, Given as number.

TABLE 7 :
Commitment and satisfaction.
N, Given as total number; n, Given as number.

TABLE 8 :
Management style of supervisors.
N, Given as total number; n, Given as number.

•
Developing mechanisms for performance enhancement of nurses by means of a formal performance appraisal system, the development of performance standards and the proper management of the nursing health workforce system.•This performance management system should address aspects such as human resources in nursing, motivation, remuneration and incentives, recognition and rewarding of professional nurses, work conditions and environment and increasing the numbers of nursing cadres.• Development of leadership and management capacity through leadership development and management programmes, courses in interpersonal relations, communication and supportive supervision.