The socio-demographic characteristics of respondents are shown in Table 1. Most doctors and AHPs were males, while nurses were mostly females. Most health professionals were less than 40 years, married, held a bachelor’s degree or less and have worked for less than 10 years.
The mean OJ score for the entire sample was 2.86 (0.73). IJ had the highest, while DJ had the lowest score. Significant differences in mean scores for overall OJ, DJ, PJ and IJ were found among health professional subgroups (Table 2).
The mean scores for DJ by SDFs are shown in Table 3. Perception of DJ differed significantly across age groups and education among doctors. Among nurses, the mean scores differed significantly by all SDFs except hospital ownership. Never married respondents had significantly higher scores than their married colleagues among AHPs.
Higher educational status a and working in state-owned teaching hospital was related to low perception of PJ among doctors (Table 4). All the SDFs had significant mean score differences among nurses. Significant mean score differences in perception of PJ were found among AHPs by age and tenure.
The mean scores by SDFs for IJ are shown in Table 5. Mean scores for IJ significantly differed by hospital ownership and education among doctors. Among nurses, only education did not show significant mean score differences in IJ. Hospital ownership and tenure showed significant mean score differences among AHPs.
Table 6 shows how specific SDFs predicted DJ, PJ and IJ among different categories of health professionals.
Unfair pay, leadership and recognition, access to hospital resources, promotional opportunities, training opportunities and work schedule emerged as key themes in DJ.
Nurses and AHPs stated that pay disparity between doctors and non-doctors is high. In contrast, doctors argued that ‘relativity (pay differences) is a global norm and should apply to Nigeria’ (Doctor 4). Whereas non-doctors stated that ‘the consolidated medical salary scale has been adjusted thrice’ (Nurse 3); doctors claimed that enhancement of the doctors’ pay scheme was to restore relativity across health professionals, which ‘has been eroding over the past 20 years’ (Doctor 2).
In the state teaching hospital, Nurses and AHPs are not paid with nationally approved salary scale ‘6 to 7 years after doctors received the new salary’ (Nurse 5). Also, the salaries of doctors are ‘about half of their contemporaries in federal-owned hospitals’ (Doctor 5). Furthermore, ‘the doctors in the State Ministry of Health receive higher pay than those in the teaching hospital’ (Doctor 5).
Leadership and recognition
Nurses and AHPs stated that doctors are more recognized in hospitals and head tertiary hospitals in Nigeria despite that ‘the act establishing teaching hospitals did not prescribe that only doctors should head hospitals’ (AHP 6). Doctors argued that the doctor should lead the health team and ‘has to oversee what is done for the patient’ (Doctor 1).
Access to hospital resources
AHPs and nurses indicated that doctors have more access to hospital resources than other health professionals. Non-doctors argued that ‘doctors have stronger power to negotiate with hospital management to get what they want’ (AHP 5) and that ‘the management singles out a particular profession to favor them in everything’ (Nurse 3). Doctors claimed that ‘doctors have fewer office space allocation than other health professionals’ (Doctor 3). Few nurses observed that AHPs ‘have more access to hospital resources than nurses’ (Nurse 5).
All health professional sub-groups agreed that promotion is often delayed, notional and without financial benefits. However, nurses and AHPs do not get promoted to the rank of director because ‘the law establishing teaching hospitals recognized only 2 directors’ (AHP 4). Nurses also stated that ‘nurses use their off-duty and shift time to go through school, but hospital management would not endorse their certificate’ for promotion (Nurse 5), unlike resident doctors. Doctors explained that although, management cannot stop nurses from unapproved in-service training, it can stop them ‘from benefiting from that degree’ (Doctor 6).
AHPs and nurses indicated that doctors have more access to training. As explained by nurses, ‘a nurse who wants to acquire further education and training does that at his own time with his own money’ (Nurse 3). Yet, ‘resident doctors are on training and receive their full salaries’ (nurse 5). Doctors argued that ‘teaching hospitals are primarily a place where doctors are trained’ (Doctor 4) ‘to improve their clinical competencies’ (Doctor 5), in contrast to other health professionals whose academic qualifications are not relevant to patient care.
AHPs and nurses indicated that ‘when doctors go for their primaries, they are reimbursed, but when others attend workshops, management will tell them that there is no money’ (AHP 2). However, doctors indicated that refunds for update courses, examinations and conferences are often delayed, ‘and when they pay, they may just pay a part’ (Doctor 4).
AHPs said that doctors take precedence over other health workers when work schedules conflicted: ‘one will be in the ward seeing a patient, the medical team comes and says my chief is here, we want to use the folder. What is this?’ (AHP 2). Nurses indicated that ‘doctors virtually leave their job descriptions to nurses’ (nurse 5). Yet, nurses are not allowed by doctors to do certain clinical procedures such as ‘administering intravenous drugs’ (Nurse 3). Doctors insisted that patient care rests on doctors, who should ‘call in anyone whose expertise is needed to give patients the best healthcare available’ (Doctor 1).
Consultation and representation, and appealing management decisions emerged as two themes in PJ.
Consultation and representation
All participants agreed that ‘managers of hospitals take most decisions without involving workers’ (AHP 6) and ‘such decisions are cascaded down to workers no matter what you think’ (Doctor 4). However, AHPs and nurses indicated that other health professionals, unlike doctors, lack power in the decision-making process in hospitals. One AHP opined that: ‘granted that doctors become chief medical directors but when it comes to choosing one, other health professionals should be involved’ (AHP 4). In contrast, doctors stated that the medical advisory committee provided a ‘platform for every profession, represented by heads of various departments, to be involved in the decision-making process’ (Doctor 2). Nurses said that ‘occasionally, they (hospital management) involve the head of nursing service but she wouldn’t come out openly to tell them what is needed’ (Nurse 4). Doctors explained that ‘nurses are mostly female, and their voice is not loud’ (Doctor 5).
Appeal management decisions
All categories of health professionals can appeal management decisions through formal reports to hospital management, but most times, such appeals have been ineffective. Labor unions represent health professionals in such appeals ‘because the civil service rule does not permit individual workers to raise issues against management’ (AHP 4). However, AHPs and nurses argued that ‘when doctors appeal unfavorable decisions, management more readily listens to them’ (AHP 6). Doctors explained that ‘those decisions would have been made in the best interest of the patient’ and ‘because of the level of people that lead the doctors… they find it much easier to interact with management’ (Doctor 5).
Enforcement of policies and procedures, information sharing, and dignity and respect emerged as key themes in IJ.
Enforcement of policies and procedures
Doctors claimed that ‘when it comes to disciplinary measures, management tend to be more ruthless with doctors than other health professionals. Hardly would you hear that a non-doctor is suspended’ (Doctor 4). AHPs and nurses stated that hospital management is more lenient with doctors in complying with policies and rules. For instance, ‘when others embarked on industrial action, their salaries were withheld, but when doctors went on strike for 3 months, they received their salaries’ (Nurse 3).
Among AHPs and nurses, information-sharing is limited because ‘the senior ones are not available most times’ (AHP 2). A supervisor would rather ‘keep information to oneself than pass it to the supervisee. Yet, when one makes a mistake, one will go in for it’ (Nurse 4). Doctors indicated that there is transition from an approach whereby the senior doctors handed over instructions to junior doctors without asking for their input to a more supportive supervisory approach. However, one doctor argued that ‘if consultants will be at work for one third of the time, the rate of mortality will drop by more than half’ (Doctor 6).
Dignity and respect
AHPs stated that supervisors treat their junior colleagues respectfully, but doctors and nurses observed that “the supervision of medical laboratory scientist is very porous” (Nurse 5). Supervision among doctors has conventionally been fault-finding in which senior doctors made derogatory statements about junior doctors before patients and other health professionals such as ‘Aturu (sheep) or goat’ (Doctor 1). A nurse observed that ‘if you see a senior registrar insulting a junior registrar, you would think that the junior doctor did not go to school’ (Nurse 4).
Furthermore, senior nurses leave duties for their younger colleagues; yet make derogatory judgements about them: “I have had a fair share of being insulted and humiliated by my senior… They blame, judge you, they make people to feel less important” (Nurse 4). Whereas doctors perceived that ‘opinions of younger nurses do not count’ (Doctor 4), AHPs explained that gender norms influenced how senior nurses treated their junior colleagues: ‘it is a profession dominated by women and they have their idiosyncrasies…if they like you, they like you; if they don’t like you, you can hardly please them’ (AHP 2).