Influence of Short-Term Employment Contracts on Performance of Health

Purpose: The study investigated the impact of short-term employment contracts on the performance of health workers at Nakuru County public hospitals, focusing on 490 contracted workers from PGH Nakuru and Naivasha Referral Hospital. Methodology: Using stratified random sampling and a sample size of 220 respondents, data was collected through structured questionnaires and analyzed with SPSS version 25 using descriptive and inferential statistics. Findings: The analysis revealed that employment continuity had a minimal and statistically insignificant effect on performance (p=.923), whereas benefits award significantly improved performance (p=.025). Increased supervision had the most substantial impact, significantly enhancing performance (p=.000). Employment relations also positively influenced performance but was statistically insignificant (p=.060). The results suggest that supervision is the most critical factor affecting the performance of short-term contract workers, followed by benefits award. In contrast, employment continuity and employment relations were less influential. Unique Contribution to Theory, Policy and Practice: The study recommends that hospitals should invest in mentorship programs to enhance employment continuity and job satisfaction, thereby improving performance. These programs would support personal and career development, contributing to better overall performance for contracted health workers.


Influence of Short-Term Employment Contracts on Performance of Health Care Workers at Nakuru County Level 4 and 5 Public Hospitals Introduction
In developing nations, strengthening health systems and increasing capacity are crucial for sustaining public health programs.A health system encompasses all organizations, institutions, resources, or people dedicated to improving health, and is based on six pillars: service delivery, human resources for health (HRH), medical supplies, financing, management, and governance (World Health Organization, 2018).Qualified and motivated HRH are essential for effective healthcare delivery, yet many resource-poor settings, including Kenya's rural districts, face severe HRH shortages (Nyikuri et al., 2015).Despite progress, such as the increase in temporary health worker hires, the shortage remains a significant challenge.
Kenya's public health sector and non-profit organizations have addressed this by employing health professionals on short-term contracts to meet demand (Jivetti, Alcántara, & Rhatigan, 2018).The "Emergency Hiring Plan (EHP)" of 2005 is a notable example of this approach, aimed at rapidly deploying various healthcare workers (Vindigni et al., 2014).Healthcare services in Kenya are delivered through a decentralized system, with national policy oversight and county-level management of service delivery (Ministry of Health, 2018).Contracting practices vary based on facility type and autonomy, with healthcare workers in Nakuru County being hired by either the county government, individual facilities, or through third-party agencies (Mwanzia & Mwangi, 2019;County Government of Nakuru, 2021).Contracts differ in terms of duration, salary, benefits, and responsibilities.Understanding the impact of temporary workforce hiring on healthcare worker performance in Nakuru County's public hospitals is crucial for improving healthcare service quality and availability throughout Kenya.

Statement of the Problem
The uncoordinated and diverse hiring practices for contracting health workers in Kenya have created challenges in fulfilling the original purpose of providing healthcare services to citizens.As short-term contracts near their end, health workers often shift their focus toward job searching, leading to reduced commitment and performance (Omondi, 2016).Additionally, future work discussions are less common with short-term employees, which can hinder organizational information flow and negatively impact performance.Contracted health workers frequently experience job insecurity, leading to anxiety and stress due to uncertainty about contract renewal.
When employees anticipate contract extensions, they may not actively seek new opportunities, which supports findings that longer contracts improve job performance (Fatoni, Prihatini & Suryaningsih, 2018).Despite the global rise in short-term employment, research on job performance in the healthcare industry has largely focused on permanent employees.This study seeks to address this gap by examining the impact of short-term employment contracts on health workers' performance in Nakuru County public hospitals.

Purpose of the study
The study aims at establishing the influence of short-term employment contract on health workers' performance at Nakuru county public hospitals.

Specific Objectives
i. To establish the influence of employment continuity on short term contract health workers' performance at Nakuru county public hospitals ii.To determine the influence of benefits award on short term contract health workers' performance at Nakuru county public hospitals iii.To examine the influence of supervision on short term contract health workers' performance at Nakuru county public hospitals iv.
To establish the influence of employment relations on short term contract health workers' performance at Nakuru county public hospitals

Performance of Health Care Workers
Public healthcare employees are essential for achieving universal health coverage and ensuring health equity and social justice.However, despite their importance, healthcare workers often receive lower benefits, including reputation and income, compared to other health employees.
Motivation is crucial for maintaining healthcare quality (Haso, Seid, & Ibro, 2018).Tabrizi et al. (2017) identified insufficient funding and a lack of human resource incentives as significant weaknesses in the primary healthcare (PHC) system in Iran.Additionally, a study by Nekoei Moghadam et al. (2017) highlighted poor personnel performance appraisal as a key factor contributing to low morale among healthcare workers.Given these challenges, interventions like performance evaluation and management support are cost-effective ways to boost productivity, starting with an assessment of the current performance evaluation system to identify areas for improvement.

Employment Continuity and Employees' Performance
Ahmed, Ahmad, and Jaaffar (2017) explored the relationship between job security and employee performance, using PLS regression analysis to assess connections among job security, employee involvement, and productivity in Bangladesh's ready-made garment (RMG) industry.Surveying 392 employees, they found that job continuity positively impacts employee performance and involvement, with the latter mediating the link between job continuity and performance.Amaechi, Eneh, and Festus (2015) examined job security's effect on performance within marketing service organizations in Calabar, Nigeria, concluding that job security is crucial for boosting performance and fostering positive relationships between employees and management.Karama (2017) conducted a study at Kyusa Uganda's Kalerwe office, finding a positive correlation between job stability and employee performance.The study advocated for formal contracts that protect employees from premature termination.Lastly, Nzuve and Njambi (2015) studied factors affecting performance at Kenya's Independent Electoral and Boundaries Commission, identifying job security, incentives, and training opportunities as key motivators that enhanced employee satisfaction and performance.

Benefits Award and Employees' Performance
Feraro-Banta and Al Shaikh (2017) investigated the impact of salary and perks on employee performance in Bahraini audit firms, analyzing compensation, allowances, promotions, and incentives.The study found a significant link between remuneration and employee efficacy.
Employees in Bahraini audit firms expressed concerns about salary issues, including mismatches between wage increases and inflation, pay disparities among different roles, and inequitable allowance distribution.Additionally, promotion criteria were unclear, and there was a lack of transparency in incentives.In Port Harcourt, Nigeria, Ekere and Amah (2014) studied the effects of rewards on job satisfaction and performance in private medical enterprises.They found that both mandatory and non-mandatory benefits positively influenced employee commitment and organizational success, with fringe benefits having a stronger impact.As benefits increased, so did employee loyalty and focus on organizational success, leading to higher performance levels.Waititu, Kihara, and Senaji (2017) examined employee welfare programs at Kenya Railways Corporation, finding that pay practices, occupational health, succession planning, developmental training, and employee referral systems positively influenced employee performance.The regression model highlighted pay practices as having the most significant impact on staff performance.

Supervision and Employees' Performance
Tesfaye (2018) explored the components of supervisory administration in companies and its benefits.The study found that supervision positively influences job performance, though organizational culture did not explain employee performance.Supervisors play a crucial role in updating employees with new skills, enabling quick adaptation to changes, as they closely monitor employees' knowledge, skills, and capacities.Nasution (2017) examined the effects of supervision and job discipline on employee performance, both separately and together.The results showed that both supervisory and discipline factors significantly and positively impact job performance.Magda, Ahmed, and Hashem (2019) investigated the impact of supervisory practices on staff nurses' quality of work life at Sohag University Hospital using a descriptive correlational design.
The study involved 240 nurses and revealed that nurses' quality of work life was high, with a significant connection to the working environment.The study also found an inverse relationship between supervisory strategies and work satisfaction, while head nurse supervisory practices directly influenced the quality of nurses' work life.

Employment Relations on Employees' Performance
Calvin (2017) conducted a study at Abdul Gusau Polytechnic, Talata-Mafara, and State College of Education Maru in Zamfara State, Nigeria, examining the relationship between employment conditions and worker performance.The research found a significant positive correlation between employee performance and compensation, including pay, bonuses, and incentives.It highlighted the importance of prompt remuneration, additional benefits, and involving employees in payrelated decisions to boost motivation.Similarly, Ongera and Juma (2015) studied the impact of short-term contracts on workforce performance at Safaricom Limited, using mean scores and standard deviations for analysis.They found that coaching, job autonomy, and contract renewal were key factors in improving employee performance and continuity.Additionally, Kemboi (2015) explored the relationship between performance contracting and employee commitment at Sikri Vocational Training Institution in Kenya.Using a cross-sectional survey approach, the study reported that performance contracting positively influenced employee commitment and productivity, with a strong and significant association between these factors and overall employee commitment.

Equity theory
Individuals assess the appropriateness of rewards by evaluating the rewards received by others for the similar labor or to another dedication they encounter (Chiekezie, Nzewei, & Orogbu, 2009).Emotions, perceptions, and a comparing process are all part of it.Equity theory argues that those who believe they are under-or over-rewarded would feel pain, and this suffering will motivate them to try new things.As a result, equity assesses each person's contribution and advantages (Idemobi, 2010).Negative situations happen once individuals accept as true that other people have received or receive higher remunerations for similar work done.Positive inequalities happen when individuals trust that they have received or receive higher benefits for similar jobs compared to others.The two situations motivate the employees.The reduction or increment of inputs for performance are the behaviours by individuals in attempting to reestablish equity for instance the behaviours would be raising the wages or salaries for uniformity across the board (French, Rayner, Rees, & Rumbles, 2011).

Social Exchange Theory (SET)
Social Exchange Theory holds that commitments are formed via a sequence of encounters between persons who are mutually reliant on one another.In other words, an exchange demands a bidirectional transaction in which something is given and something is repaid, which may be viewed as a mutual collaboration existing between the hired and the employer (Robinson, 2004).Saks (2006) highlighted that one way for individuals to repay their employer is via their level of participation.According to Saks (2006) employees are more willing to barter their allegiance for Vol.6, Issue No.6, pp 31 -51, 2024 www.carijournals.org36 inputs and perks offered by the organization.Workers are more likely to be engaged when they are self-sufficient, get assistance, and have opportunities for progress.Social Exchange Theory provides a theoretical foundation for explaining why employees' engagement varies, i.e. why people engage more or less in their work.

Methodology
The study employed a cross-sectional research approach, utilizing quantitative data.It targeted 490 contracted health workers from Nakuru County's Level 4 and 5 public hospitals.A stratified random sampling technique was used to select a sample, with simple random sampling for healthcare professionals.A total of 220 healthcare workers, representing 45% of the target population, were sampled from Naivasha Referral Hospital and PGH Nakuru Referral Hospital, using Yamane's (1967) formula.Primary data was collected through structured questionnaires.
The data was coded and entered in SPSS version 25.0.The study used descriptive statistics to analyze the quantitative data and further presented it in the form of tables, charts and bar graphs while the interpretation was done by the use of prose.An ordinal regression was used in the study to evaluate the link between the dependent variable and independent variables.

Results and Discussion
The study achieved a response rate of 173(78.6%)which was considered sufficient (Mugenda and Mugenda, 2009).The results are presented starting with respondents' basic information.See Table 1.

Employment Continuity
The results show that majority 137(79%) of the respondents agreed that the assurance of career stability motivated contracted workers to perform; 137(79%) agreed that the communication on changes of employment terms was done in advance and 144(84%) of the respondents agreed that promise for permanent employment affects their morale and productivity.Moreover, 141(82%) agreed that they were given the sense of belonging once they started working with the health organizations.In addition, 128(74%) agreed that they anticipated long-term employment with the hospital at the point of employment.On the contrary 90(52%) disagreed that they were actively engaged in other duties outside official responsibility.The results imply that the respondents were aware of all the aspects that would lead to employment continuity as contracted employees.See Table 2.The findings agree with Ahmed, Ahmad and Jaaffar (2017) that job continuity influences performance and involvement of the employees which arbitrates the link the exists between job continuity and performance and therefore the concept was expected to be used in poor countries to improve employee performance.The study found that contract duration influenced the performance of health care workers.

Benefits Award
The results show that 129(75%) of the respondents agreed that continuity of employment gave a sense of job security and is a source of motivation and 129(75%) agreed that financial awards influence their performances.In addition, 120(69%) disagreed that there was inclusion of retirement plans in employment contracts that influenced their performance and 111(64%) agreed that employees with short-term contracts have right to maternity leave.Moreover, 130(75%) of the respondents agreed that their contracts have a health insurance cover.Further, 83(48%) of the respondents agreed that short term contracted employees were paid lower than long and 104(60%) disagreed that short-term employees were not paid for days they have been absent from work.The results imply that the respondents were aware of the role played by the rewarding in their personal and collective performance within the health organisations.The study found that health insurance influenced the performance of health care workers.See Table 3.The findings agree with Liu and Zhang (2018) that retirement plans that offer generous benefits and early retirement options can have a positive impact on job satisfaction and retention among healthcare workers.However, the study also found that retirement plans that do not offer early retirement options can have a negative impact on job satisfaction and performance, particularly among older workers who may be more likely to experience burnout and fatigue.

Level of Supervision
The results show that 114(66%) of the respondents agreed that their supervisors offered technical support which helped in the achievement of performance targets.Further, 67(39%) of the respondents agreed that their supervisors gave them freedom to make constructive decisions at my work station and 86(50%) disagreed that supervisors always recommended their rewarding when performed optimally.See Table 4.The study found that tracking results influenced the performance of health care workers.The study found that rewarding workers influenced the performance of health care workers.The findings agree with Hsieh and Hsieh (2019) that financial incentives were effective in increasing the quantity and quality of care provided by healthcare workers.The study found that technical support influenced the performance of health care workers.

Employment Relations
The outcomes show that 101(58%) of the respondents agreed that the hospitals had incorporated safety issues in the employment contract.In addition, 81(47%) of the respondents disagreed that the contract of their employment had incorporated mandated break times and 85(49%) agreed that short term employments were used as recruitment channel of potential employees.Moreover, 79(45%) of the respondents agreed that their minimum wage had been well captured in the employment contract and 89(51%) moderately agreed that short term contracted employees were hired as backup labour.See Table 5.The findings are in line with Ongera and Juma (2015) that Safaricom Limited was encouraged employee employability through coaching and job autonomy, as well as enhancing their employment continuity through contract renewal.The study found that safety issues influenced the performance of health care workers.The findings agree with Gerberich et al., ( 2015) that exposure to workplace violence lead to increased rates of depression, anxiety, and post-traumatic stress disorder (PTSD) among healthcare workers.Also the findings are in line with Liu et al. (2020) that the COVID-19 pandemic has highlighted the importance of protecting healthcare workers from exposure to infectious diseases.Lack of personal protective equipment (PPE) and other safety measures has led to increased rates of infection and mortality among healthcare workers during the COVID-19 pandemic.

Healthcare Employees' Performance
Results shows that majority 131(76%) of the respondents agreed that they performed their work with a lot of accuracy and 98(56%) worked under minimum supervision.In addition, 106(61%) of the respondents agreed that they got support from their teams whenever they needed it and 116(67%) agreed that they performed their duties in a timely manner.See Table 6.The study found that short-term employment contracts influenced the productivity of health care workers.
The findings agree with García-Sierra et al. ( 2016) that healthcare workers with short-term contracts had lower job satisfaction and were more likely to experience burnout than those with permanent contracts in Spain.Also agree with Bayram et al. (2017) that temporary contracts were associated with lower levels of job satisfaction and higher turnover intentions among healthcare workers.Further agreed with Campanini et al. ( 2016) that temporary contracts were associated with a higher level of job strain among healthcare workers.The study found that short-term employment contracts influenced the innovation of health care workers.Also agree with Hesselink et al. (2015) that temporary nurses in the Netherlands were less likely to engage in quality improvement activities than permanent nurses.The study found that short-term employment contracts influenced the punctuality of health care workers.The findings agree with McInerney and Mellor ( 2011) that nurses on short-term contracts were significantly more likely to be late for work than those on permanent contracts.I contribute innovative ideas that benefit the organization 12( 7) 90( 52) 71( 41) My team is an inspiration for me to do my best at the job 11( 6) 91( 53) 71( 41) I proficiently use work related equipment, tools and technology 44( 25) 63( 36) 66( 38)

Ordinal Logistical Regression
In modeling the predictive power of the independent factors influencing the performance of contracted health care workers at Nakuru County public hospitals, the researcher adopted an ordinal logistical regression to determine the Case Processing Summary, Model Fitting Information, Goodness-of-Fit and Pseudo R-Square.

Model Fitting Information
The outcomes show that the model was statistically significant as the significance value was below .05.In this case there is a significant improvement of the final model over the null model {X 2 (4) = 27.332,p=.000}.Therefore, the model was significant in determining the relationship between the study variables.See Table 7

Goodness-of-Fit
The goodness-of-fit is aimed at testing the null hypothesis.The Pearson and deviance significance value are above .05the which rejects the null hypothesis (short-term employment contracts had no significant influence on the performance of health care workers) with values .236and 1.000 respectively.Therefore, the alternative hypotheses (short-term employment contracts had significant influence on the performance of health care workers) approved thereby implying that that the employment continuity, benefits award, level of supervision and employment relations were significant determinants of performance of health care workers.See Table 8.

Cox and Snell R-squared and Nagelkerke R-squared
The study considered measures that are similar to R 2 in ordinary least-squares regression, which is the proportion of variance that can be explained by the model.In multinomial ordinal logistic regression, however, these are the pseudo R

Parameter Estimates
The study employed the parameter estimates in determining and understanding the relationships between the independent and dependent variables.See Table 10.  10 show that a unit increase in employment continuity would lead to a .036decrease in short term contract health workers' performance at Nakuru county public hospitals.Employment continuity did not significantly influence the performance of health workers on short term contracts (p=.923>.05).Further the outcomes show that a unit increase in benefits award would lead to .646increase in short term contract health workers' performance at Nakuru county public hospitals.Benefits award significantly influenced the performance of health workers on short term contract (p=.025<.05)Nakuru county public hospitals.In addition, the results show that a unit increase in level of supervision would lead to 1.261 increase in short term contract health workers' performance at Nakuru county public hospitals where it significantly (p=.000<.05)influenced the short term contract health workers' performance at Nakuru county public hospitals.
Finally, the outcomes show that a unit increase in employment relations would lead to .832increase in short term contract health workers' performance at Nakuru county public hospitals where it insignificantly (p=.060>.05)influenced the short term contract health workers' performance at Nakuru county public hospitals.
The results imply that the level of supervision was the most significant influencer of short term contract health workers' performance at Nakuru county public hospitals with significance values of .000.The finding agrees with Tesfaye (2018) that the organization can keep employees updated with new skills and knowledge, allowing them to swiftly adjust to changes in their primary duties as supervisors are capable of immediately know the employee's knowledge, skills, and capacities.Also in line with findings of Bradley et al. (2013) that effective HRM and supervision necessitates monitoring which in turn promotes the performance and retention of staff.Further, the results imply that the benefits award was significant influencer of short term contract health workers' performance at Nakuru county public hospitals with significance values of .000and .025respectively.The findings are in line with Feraro-Banta and Al Shaikh (2017) that there was a significant link between employee remuneration and benefits in staff efficacy.

Test of Parallel Lines
The outcomes for the test of parallel lines (assumptions of proportional odds) indicate a nonsignificance (p=.458>.05)implying that the assumption has been satisfied.This means that the coefficients for each predictor variable are the same across all levels of the dependent variable, and that the relationship between the predictor variables and the dependent variable is constant across all levels of the dependent variable.Further, suggests that the ordinal regression model is appropriate for the data, and that the relationship between the predictor variables and the dependent variable does not vary significantly across different levels of the dependent variable.See Table 11.The null hypothesis states that the location parameters (slope coefficients) are the same across response categories.
b.The log-likelihood value cannot be further increased after maximum number of step-halving.
c.The Chi-Square statistic is computed based on the log-likelihood value of the last iteration of the general model.Validity of the test is uncertain.

Conclusions
The study concludes that employment continuity insignificantly influence performance of short term contract health workers at Nakuru county public hospitals.Further, the study concludes that the workers were not always actively engaged in other duties outside official responsibility and that the communication on changes of employment terms was rarely done in advance.Also, the study concludes that benefits award significantly influenced the short term contract health workers' performance at Nakuru county public hospitals.In addition, the study concludes that employees with short-term contracts have right to maternity leave.
The study established that level of supervision significantly (p=.000<.05)influenced the short term contract health workers' performance at Nakuru county public hospitals.The study further concludes that the supervisors offered technical support which helped in the achievement of performance targets.Further, the study concludes that the supervisors did not give them freedom to make constructive decisions at the work station and that the supervisors did not always recommended their rewarding when performed optimally.
The study established that employment relations insignificantly (p=.060>.05)influenced the short term contract health workers' performance at Nakuru county public hospitals.The study concludes that the hospitals had incorporated safety issues in the employment contract.In addition, the study concludes that the contract of employment incorporates mandated break times and that short term employments were used as recruitment channel of potential employees.Moreover, the study concludes that the minimum wage had been well captured in the employment contract and that short term contracted employees were not hired as backup labour.Also, the study concludes that short term contracted were not hired as unskilled labour.

Recommendations
The study recommends that hospitals should invest in mentorship programs to enhance contracted workers' personal and career growth, promoting job satisfaction and performance.It suggests implementing a performance-based reward system and improving supervision quality through better evaluation and monitoring approaches to boost individual and organizational outcomes.The study also advises the county government and hospitals to explore ways to improve remuneration for contracted healthcare workers.Finally, it recommends abandoning the authoritative leadership style in favor of a horizontal approach, which simplifies communication and hierarchy in employment relations.
The necessity for variable correlation motivates the usage of multiple regressions.The regression equation was: logit (P (Y ≤ j | X)) = β1X1 + β2X2 + β3X3 + β4X4+ ε P (Y ≤ j | X) = Performance of Contracted Healthcare Workers; X1 = Employment continuity; X2 = Benefits award; X3 = Level of supervision; X4 = Employment relations β0 = Constant β1 β2 and β3 = coefficients of variables & ε = error term 2 measures.SPSS Statistics calculates the Cox and Snell, Nagelkerke and McFadden pseudo R 2 measures.See Tables 9more complete compared to Cox and Snell.The range of values for Nagelkerke fall between 0 and 1.It measures the proportion of the total variation of the dependent variable can be explained by independent variables (Employment Continuity, Benefits Award, Level of Supervision and Employment Relations) in the current model.Therefore, Nagelkerke Rsquared was preferred in this study as it is more complete compared to Cox and Snell and it explained 38% of the variance of the dependent variable (Performance of Health Care Workers).

Table 5 : Healthcare Employees' Performance Disagree Moderately Agree
.