TABLE OF CONTENTS
Content Page
Title page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract vi
Table of Contents vii
List of Tables x
List of Figures xi
List of Appendices xii
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 6
1.3 Objective of the Study 8
1.4 Research Questions 8
1.5 Hypotheses 9
1.6 Significance of the Study 9
1.7 Scope of the Study 9
1.8 Operational Definition of Terms 10
1.9 Chapter Outlay 11
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 12
2.1 Policy 12
2.2 Health policy 14
2.3 Hospital policy 15
2.3.1 Educational development 16
2.3.2 Wage and salary 17
2.3.3 Nurse to patient ratio 17
2.3.4 No work, no pay 18
2.4 Attitude and work attitude 18
Content Page
2.4.1 Causes of employee attitude 19
2.5 Service delivery 21
2.5.1 Health care service delivery 23
2.6 Employee performance 25
2.6.1 Employee participation and performance relationship 27
2.7 Patients’ satisfaction 28
2.8 Health sector organization and their environment 29
2.8.1 Conceptual model 31
2.9 Empirical review 33
2.9.1 Attitude and service delivery 33
2.9.2 Motivation and service delivery 35
2.9.3 Management and service delivery 37
2.9.4 Service delivery through patient-centred care 39
2.9.5 Barriers to patient-centred care 41
2.10 Theoretical framework 43
2.10.1 Motivation theory – Herzberg two factor theory 43
2.10.2 Behavioral organizational theory 46
2.11 Gap in Literature 48
2.12 Conclusion 49
CHAPTER THREE: METHODOLOGY
3.0 Introduction 51
3.1 Research design 51
3.2 Population 51
3.3 Sample size and sampling Technique 52
3.4 Instrumentation 53
3.5 Reliability test and validity of instrument 54
3.6 Method of Data Collection 54
3.7 Method of Data Analysis 55
3.8 Ethical consideration 55

CHAPTER FOUR: DATA ANALYSIS AND DISCUSSION OF FINDINGS
4.0 Introduction 56
4.1 Socio demographic analysis of respondents 56
4.2 Analysis of questionnaire items 60
4.3 In-depth interview 71
4.4 Test of hypotheses 77
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Summary 85
5.2 Conclusion 85
5.3 Recommendations 86
5.4 Limitation of the Study 86
5.5 Contribution to Knowledge 86
5.6 Implications for Policy 87
5.7 Suggestion for Further Studies 87
REFERENCES 88
APPENDICES 96

LIST OF TABLES
Table Page
1 Summary of reliability test 54
2 Socio Demographic data of the respondents 56
3 Questions addressing Policies 60
4 Questions addressing nurses’ work attitude 64
5 Questions addressing patients’ satisfaction 66
6 Questions addressing service delivery 68
7 In-depth interview guide 71
8 Regression result for policies vs nurses’ attitude 77
9 Regression result for nurses’ attitude vs service delivery 79
10 Regression result for nurses’ attitude vs patients’ satisfaction 81
11 Regression result for service delivery vs patients’ satisfaction 82

LIST OF FIGURES
Figure Page

1 Conceptual Model 31
2 Herzberg’s two factor theory 45

LIST OF APPPENDICES
Appendix Page
1 Raw Pilot Study data 97
2 Informed consent form 98
3 Questionnaire for nurses 99
4 In-depth interview consent form 104

1. In-depth interview guide 105
2. Turn it in report

CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Despite bold plans and massive injections of international and domestic resources, public service delivery is still failing in many areas in several developing countries. This according to Mcloughlin and Bately (2012) suggests there is a need to revisit approaches to rendering assistance to service delivery sectors. It is also necessary to focus on understanding how a range of institutional and governance arrangements can shape service delivery processes and outcomes. They went further to say that while the number of political economy studies on different service delivery sectors and different countries is growing, these remain largely one-off or ad hoc studies. Thirdly, their study tends to talk in fairly generic terms about political and governance constraints. For example, concepts like ‘political will’ or the existence of ‘weak incentives’ are often referred to but rarely further developed in terms of the specific institutional and governance arrangements that contribute to these factors, and in terms of which of these may offer strategies for overcoming common bottlenecks or gaps ( Mcloughlin, Batley, 2012). Therefore, the justification for a service delivery reform may lie on the need for efficiency, effectiveness, and accountability (Lufunyo, 2013)
The tools and strategies used by stakeholders to achieve their policy objectives have also evolved and it is now common place to refer to governance as a range of old and new tools and instruments through which public policy goals may be achieved and/or delivered (Zito, Radaelli, Jordan, 2003; Hood, 2006). The very concept implies that the ways to govern the public sector and the tools for doing so have changed (Salamon, 2002) and – implicitly or explicitly – should change further from old command-and-control, public administration or management models (Bovaird, Löffler, 2003). The importance of policy or its implementation cannot be overemphasized particularly as it relates to health. This is becausehealth is an essential component of development, necessary for a nation’s economic growth and internal stability. It is a necessity for everyday life, not the object of living, but a positive concept emphasizing social and personal resources as well as physical capabilities. This may be said to explain the popular saying that a healthy nation is a wealthy nation. It is further emphasized by the definition of World Health Organization (WHO), (1946), that good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.
To ensure that everyone has access to quality health, the Universal Declaration of Human Rights (1948), recognizes health as a fundamental human right. This means that the relief or cure of ill health is universally important and this makes it imperative to ensure that high quality services are provided in response to developments in medicine and the desire of the caring professions to aspire to clinical excellence (Sewell, 1997). Governments therefore have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. It may not be wrong therefore for one to reason that health and healthcare delivery can be viewed from a system perspective characterized by complexity and interconnectedness, where everything affects everything else.
Healthcare in communities and hospitals have become increasingly important, even as they face fundamental changes in their service delivery patterns (McKee & Healy, 2002; Lee, Chen & Weiner, 2004). The hospitals are governed by a set of processes and tools related to decision-making in steering the totality of institutional activity, influencing most major aspects of organizational behaviour and recognizing the complex relationships between multiple stakeholders otherwise called policy (Richard, Saltman Antonio Durán Hans, & Dubois, 2011). The policies governing hospital according to Ricard et al (2011) has a scope that ranges from normative values (equity, ethics) to access, quality, patient responsiveness, and patient safety dimensions. It also incorporates political, financial, managerial as well as daily operational issues.
In view of the foregoing, issues in healthcare need to be viewed holistically as integrated system of multiple components (people, organization, technology and resources) and perspectives (Health Systems, 2012). In furtherance of this, several researchers have posited on the challenges faced in the provision of evidence-informed health care, one of which is the right intervention to the right people at the right time in routine settings. While Marchal, Cavalli, and Kegel, (2009), Green and Collins, (2003) have observed that this challenge is particularly acute in low income settings, English, Ntoburi, Wagai, Mbindyo, Opiyo, Ayieko,…Irimu (2009) have gone on to describe the specific major failures in hospital care in Africa.
Here in Nigeria, staff attitude has been attributed to the poor health care delivery (Akerele, 1986; Maduabum, 1990; Afolabi & Erhun, 2003). Affirming this, the Federal Ministry of Health (2007), reported that the poor state of Nigeria’s health system is traceable to several factors; organization, stewardship, financing and provision of health services.
Attitude is an internal state that influences individual’s choices of personal action (Bianey, Ulloa, Adams, 2004). The attitude of the health care employee can affect service delivery either positively or negatively. In other words, attitudes are good predictors of behavior and they provide clues to an employee’s behavioral intentions or inclination to act in a certain way. According to Newstrom (2001), positive job attitude helps predict constructive behaviors, while negative job attitude helps predict undesirable behavior. Employee attitudes and behaviors are important factors in service encounters, with committed employees, particularly the frontline staff, linked with increased levels of customer satisfaction (Ballout, 2007). This is to ensure that organizational values such as the provision of quality service is established and sustained.
The Royal College of Nursing of the United Kingdom (GB) explains the difference between a professional nursing attitude, which is, values nurses hold as well as their thoughts and feelings; to behavior, which is what nurses actually do. It is therefore suggesting that a factor like working environment can prevent nurses from enacting their professional values, while affirming that sometimes things can go wrong. In hospitals, interaction between nurses and stakeholders has always been critical in determining whether patients experience satisfaction or dissatisfaction in the provision of inpatient and outpatient healthcare services (Zangaro & Soeken, 2007). The provision of poor-quality care has often been attributed to inadequate knowledge and skills compounded by broader system failures and low staff numbers. This has given rise to the need to tackle inadequate human resources for health (HRM), which also was noted as an essential part of strengthening health system and emphasized in the 2006 World Health Report.
However, the focus of attention has been on macro-level issues related to workforce, training, recruitment, retention, skill mix and distribution. More recently, attention has turned to the capacity of health workers, their motivation and other structural and organizational aspects of systems that influence performance than ways to satisfy the needs of the patients (Bradley, Youngkyoo, Cook, Sache, Donabedian, 1996). Notwithstanding the catalogue of researches carried out on the healthcare delivery system and several recommendations proffered, the perception of Nigeria’s hospitals, particularly the public ones are still very far from being impressive.
The aim of this study is to highlight the effect of service delivery policy on the work attitude of nurses and go on to investigate how this affects patients’ satisfaction in two Nigerian hospitals, Lagos University Teaching Hospital (LUTH) and Babcock University Teaching Hospital (BUTH). Both hospitals come under tertiary or referral hospitals which provide health care by different specialists after referral from primary care or secondary care centers.
A tertiary or teaching hospital is a hospital or medical center that provides clinical education and training to future and health professionals. Teaching hospitals are often affiliated with medical schools and work closely with medical students throughout their period of matriculation and especially during their internship. In most cases, teaching hospital offer Graduate Medical Education (GME), physician residency programs, where medical school graduates train under a supervising specialist to assist with the coordination and provision of highly specialized clinical care to the most severely ill and injured. In addition to this, many teaching hospitals also serve as research institutes. Teaching hospitals exist under two categories – public and private. A public teaching hospital or government hospital is a hospital owned by government and receives government funding. In some countries, this type of hospital provides medical care free of charge, the cost of which is covered by government reimbursement. In Nigeria, the cost of treatment is not entirely free but highly subsidized. An example is the Lagos University Teaching Hospital.
Lagos University Teaching Hospital started in 1962 with three hundred beds but today has more than eight hundred beds and has through the years provided health personnel to Nigeria’s health sector with about 32,488 doctors and more than 3,819 nurses having undergone training in the institution. When it took off, LUTH had ninety four nurses of all cadres in its employment and by its 50th anniversary in 2012, it had seven hundred and twenty seven nurses comprising of, Assistant Director, Nursing Services (1), Chief Nursing Officers (119), Asst. Chief Nursing Officers (112), Principal Nursing Officers (142), Snr. Nursing Officers (52), Nursing Officer (8), Nursing Officer 1 (60), Nursing Officer II (72), Staff Nurse Midwife/Nursing Sister (99), Midwife Sister/ Nursing Supt. (6), Temp. Staff Nurse/Staff Nurse/Staff Midwife (57).
Mrs Adewunmi, one of the first nurses of LUTH in an interview in 2012, described the nurses’ relationship with patients at that time as friendly. This is exhibited such that twenty five years after retirement and fifty years after the inception of the hospital, she could still remember the name of the first surgical patient of the hospital as Mr. Apanisile, who according to her, after his hospital discharge sought and got employed as the hospital’s barber for many years. To the nurses at that time, the patients came first in the hospital and because they were well looked after, patients enjoyed coming to the ward/ hospital.
A private teaching hospital is a hospital owned by a private university and privately funded through payment for medical services by patients themselves, by insurers, governments through national health insurance programs, or by foreign embassies. An example is the Babcock University Teaching Hospital established by the Seventh Adventist Church, and an upgrade of the former Babcock University Medical Center. it officially took off in 2011 with a total of 34 nurses and by 2015, the number had increased to 178. This is made up of, Director of Nursing Services (1), Chief Nursing Officers (6), Assistant Chief Nursing Officers (7), Principal Nursing Officers (11), Nursing Officers 1 (13), and one hundred and Nursing Officers (135).
Observably, the highest cadre, chief nursing officer, in the Lagos University Teaching Hospital, has the highest number of nurses, 119, as against the highest number of 135 nurses being in the lowest cadre, nursing officer, in the Babcock University Teaching Hospital. It may be pertinent to also note that that the nitty gritty of the nursing care is usually undertaken by the nursing officers while the chief nursing officers act mostly as supervisors.

1.2 Statement of the Problem