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Improving motivation among health care workers in private health care organizations
A perspective of nursing personnel
Zydziunaite Vilma
Kaunas University of Technology, Kaunas, Lithuania, and

Motivation among health care workers 213

Katiliute Egle
Vytautas Magnus University, Kaunas, Lithuania
Abstract
Purpose The study aims to explore the experiences of nursing personnel in private health care organizations in Lithuania, in terms of their work motivation and satisfaction, promotion and quitting the job, interpersonal interaction at work and to identify areas for sustainable improvement to the health care services they provide. Design/methodology/approach The research problem includes the following questions. What is the attitude of nursing personnel to the existing elements of motivation in private health care organizations? What organizational tools should be developed in order to improve the motivation of nursing personnel? The sample consists of 237 registered nurses practitioners and 30 nurses managers working in private health care sector. Methods: data selection: questioning survey; data analysis: descriptive statistics, correlation and factor analysis (using SPSS for Windows 12.0). The research instrument involves 99 closed-ended items divided into 11 evaluation blocks; Cronbach a of every part ranges from 0.68 to 0.85. Findings Results showed no statistical differences among nurse practitioners and executives of what motivates them in private health care organization as workplace and illuminated factors that decrease and increase motivation among nurses. Motivation decreases, when nurses are not empowered not autonomous in activity; nurses competencies (specic professional and general) are not applied in full value, e.g. managerial, educational, social-psychological, clinical/expertise; decisions are not made collectively; in organization does not exist mechanism of information-sharing; meetings of personnel are not prepared methodically. Motivation increases when the nurses collaborate with physicians by parity; nursing profession is respected and recognized as autonomous and valued by themselves and other health care specialists; the interpersonal communication is effective and conicts are solved constructively. Research limitations/implications A major weakness is that the characteristics of the present sample may limit the generalizability of the results. The major implication is that the paper supports the prediction for characteristics of motivation among health care workers in private health care organizations with perspective of nursing personnel. Originality/value The paper examines in a private health care sector the factors that increase and/or decrease the motivation of nursing personnel. Keywords Motivation (psychology), Private hospitals, Health services, Nurses, Lithuania Paper type Research paper

Motivation among health care workers: perspectives of nursing personnel The question of how to improve the motivation of personnel among health care workers is quite properly perceived to be at the heart of the contemporary

Baltic Journal of Management Vol. 2 No. 2, 2007 pp. 213-224 q Emerald Group Publishing Limited 1746-5265 DOI 10.1108/17465260710751008

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health care management debate (Glen, 1998; Chiu, 2005). Managerial concerns related to employee motivation are not new (Herzberg et al., 1959; Vroom, 1964), but questions concerning motivational incentives and employees perceptions of what motivates them in the workplace continue to be discussed and analyzed. Motivation is a frequently cited rationale underlying the adoption and maintenance of health behaviors in research and practice (Carter and Kulbok, 2002; Grafham et al., 2004). Motivation is complex and multidimensional, and clearer denitions for motivation are needed. Researchers and practitioners are challenged to examine carefully the role of motivation for health behaviors and explore other factors that may more strongly inuence behaviors of health care workers. Many contemporary authors have dened motivation. Kreitner (1995) and Grafham et al. (2004) refer to motivation as a psychological process that gives direction to behavior; Higgins (1994) and Begat et al. (2005) dene motivation as an internal drive that is present to satisfy unmet needs; Bedeian (1993) and McLean and Anema (2004) describe motivation as a will to achieve. Nahavandi and Malekzadeh (1999) associate the concept of motivation with management issues related to organizational performance. They dene motivation as a state of mind, desire, energy, or interest that translates into action. This action is viewed as work performance. The belief is that this performance can be inuenced when employee motivation is inuenced. Employee motivation can be inuenced due to motivation being a exible state of mind. The present era of cost containment pressures means that nurse executives need to ensure that nurses have a work environment with the characteristics of work known to be linked to job satisfaction, motivation and good outcomes, e.g.: the key to improvement in health care practice may be the improvement of relationship between motivational tendencies, professional development and personal development among health care professionals (Glen, 1998; Iley, 2004); the autonomy, communication, adequate time for patient care (Aronowitz and Munzert, 2006) and the degree of environmental uncertainty contributed to job satisfaction and work motivation of nursing personnel (Freeman and OBrien-Pallas, 1998; Edgar, 1999; Oweis, 2005); the helping pathways such as reward seeking, altruism, and punishment-avoidance are the work motives for caregivers (Smith et al., 2001); general job satisfaction, general job happiness, satisfaction with salary and promotion, institution, educational background are proved to be signicant predictors of nurses decrease of work motivation (Tzeng, 2002; Davidhizar, 2004). Articles on improvement of motivation in private health care sector are limited. Among the health professional journals, nursing literature has the most on managerial aspects, motivation and job satisfaction without differentiation to public or private health care sector. Nevertheless, in some articles is presented such kind of research-based information. Munro (1983) indicated that working conditions, status and security may operate as motivators within nursing profession; Rantz et al. (1996) identied the achievement, recognition, work itself, responsibility and advancement as motivators of nurses; Smith (2000) described a study on job satisfaction that was done with occupational therapists and the job characteristics of feedback on the job, task signicance, autonomy and skill variety showed the greatest impact on job satisfaction. Janssen et al. (1999) proposes four central domains of the work situation, namely work content, working conditions, social and labor relations, and conditions of employment, which

could increase or diminish the intrinsic work motivation of nurses. Employee empowerment may be inuenced by the perception that the organization cares about its employees well-being and that their work is valued. Morrison et al. (1997) and Amundsen, Corey (2000) indicate that the leadership style and empowerment inuence job satisfaction and work motivation among health care workers. Nevertheless, the emotional intelligence of nurse executives and nurses practitioners is prerequisite for their work motivation (Cadman and Brewer, 2001). The research studies of McNeese-Smith (1998) and Foster (2000) examined the relationships among nurse managers motivation for power, achievement and afliation, managerial leadership behaviors, staff nurse outcomes of job satisfaction, productivity and organizational commitment and patient satisfaction. Results showed that managerial motivation for power is negatively correlated with manager use of leadership behaviors and staff nurse job satisfaction but positively correlated with patient satisfaction. Managerial motivation for achievement is positively correlated with use of leadership behaviors as well as nurse job satisfaction and work motivation, productivity and organizational commitment, and generally to patient satisfaction. Motivation, leadership skill development, and a responsive environment relate to staff nurses self-efcacy development (George et al., 2002; Iley, 2004). Authors also indicate that the professional nursing practice autonomy, leadership behaviors improves the nurses work motivation and patient outcomes too. The studies of Hertting et al. (2004) and Secrest et al. (2005) demonstrate the importance of analyzing feelings relating to professional ambiguity and stress. Also they give emphasis to considerations relating to differences in the age, care philosophy, and psychosocial health conditions of nurses. The concurrence of ever-growing job demands and work going unrewarded contributes to a feeling of being taken advantage of by the employer. The well-being of nurses and improvement of work motivation depends on being an equal/parallel health professional in a comprehensive team that shares knowledge and improves collaborative care of patients and a consciously formulated nursing philosophy at health care organization. But there is no differences in nurses job satisfaction or work motivation in different organizational structures or where different nursing care delivery models were used. A supportive working (Kangas et al., 1999) and learning (Jang et al., 2005) environments are the most important to the job satisfaction of nurses. Young et al. (1997) and Kennedy et al. (2005) indicate the authority to initiate independent nursing actions, individual accountability for clinical outcomes, and regular performance feedback from managers and factors motivating the nurses work motivation. Methodology The multidimensional concept of motivation has been noted in the literature as difcult to dene due to an inability to directly observe it. By observing ones behavior, conclusions are typically drawn regarding motivation. The assumption is made that an inner drive directs and maintains motivation that results in certain behaviors. With this inner drive nature of motivation, it may be best measured through self-reection of a variety of situations related to what motivates or what constrains one from being motivated in the workplace. For the purposes of this study motivation is dened as the inner force that drives the nurse to accomplish personal and organizational goals. The various factors associated with improvement of motivation,

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including application of competencies, activity environment, communication and collaboration, responsibility, results and encouragement, autonomy, self-realization, activity purposefulness in the study were categorized as motivators. Research design A questionnaire was given to 237 registered nurse practitioners and 30 nurse executives working in private health care sector. Returning quota of questionnaires is 97 percent. Sampling was non-probability, purposeful. Research participants were from ve (biggest) towns in order to represent all the geographical areas of Lithuania. Instruments Research instrument consisted of 99 closed-ended items divided into 11 evaluation parts: (1) rst part with nine items application of social-psychological competencies; (2) second part with 9 items application of clinical-expertise competencies; (3) third part with 9 items application of educational competencies; (4) fourth part with 9 items application of managerial-administrational competencies; (5) fth part with 9 items activity environment; (6) sixth part with 9 items communication and collaboration; (7) seventh part with 9 items responsibility; (8) eighth part with 9 items results and encouragement; (9) ninth part with 9 items autonomy; (10) tenth part with 9 items self-realization; (11) eleventh part with 9 items activity purposefulness. Reliability of every part ranges from 0.68 to 0.85. In order to identify constraints an instrument item was chosen that reects barriers to motivation. The repeated statement on the improvement of work motivation questionnaire states I believe my professional I and overall motivation would suffer most in a job situation wherein . . . This may be interpreted as a constraint due to the indication of something limiting motivation on the job. The respondent then distributed ve points between the two responses that followed. The two responses reect external (activity environment, communication and collaboration, results and encouragement, autonomy, activity purposefulness) and internal (self-realization, responsibility, application of competencies) motivators, respectively. The numbers given to each response indicated what is more or less characteristic of an individual. If an item was evaluated as possible in three motivation categories of the instrument, this was only identied as a notable. Reliability for the entire questionnaire has been established at 0.70. Construct validity is high, yielding a correlation of 0.82. Methods Data selection: questioning survey. Data analysis: descriptive statistics, correlation and factor analysis (using SPSS for Windows 12.0).

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Findings of the study Application of social-psychological competencies In private health care organizations nurses practitioners are not treated as equal partners in team-working, have no possibilities to show the professional condence and to manage the conicts autonomously. But nurse practitioners are helpful, open, empathic, patient and tolerant (Figure 1). Nurse executives realize the collaboration and conict management competencies in full value, but they lack empathy and tolerance. Application of clinical-expertise competencies The nurse practitioners indicate that they perform effectively the assessment of patients state, but poorly realize competencies of reection on activity, evaluation of activity mistakes and concrete work situation, and minimization of patients stress (Figure 2). Nurse executives note that they perform efciently competencies of problem-solving and evaluation of activity mistakes and results.
collaborate with physicians by parity confidence conflict management interpersonal help openess empathy listening tolerance patiency 0% 20% possible 40% 55 88 97 60% partly 80% not possible 22 34 40 64 9 20 32 12 31 34 33 20 31 71 56 47 32 27 16 14 10 2 30 100%

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Figure 1. Application of social-psychological competencies (nurse practitioners)

reflecting activity diagnosing activity mistakes releasing the stress of the patient evaluating situation analysing problem solving collecting information evaluating activity results and mistakes assessing patient's state

13 11

3 10 31 31 64 52 73 34 88 20 20

84 79 49 49 20 34 14 60 16 14 13 6 8 4 60% partly 80% 100%

0%

20% possible

40%

not possible

Figure 2. Application of clinical-expertise competencies (nurse practitioners)

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Application of educational competencies Nurse executives do not perform the following competencies: learning in teams, patients education and knowledge utilization. Nurse practitioners the most effectively realize the self-empowerment for professional development (Figure 3). Application of managerial and administrational competencies Nurse practitioners most successfully realize the competencies of personnel empowerment for continuing development and evaluation of personnel problems (Figure 4). Nurse executives mention the same competencies as effective too. Both nurses practitioners and executives indicate that they do not realize the development of teamwork competencies, structuring of activity scope and implementation of teamwork in full value. In presentation the results of factorial and correlation analyses the data selected from nurse practitioners and executives were integrated.

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learning in teams 0 3 preparing teaching material learning by collaboration education of colleagues patient's education counseling (patients and colleagues) knowledge utilization 23 3 11 9 7 18 26 53 64 0% 20% possible 40% 9 21 10 13

97 95 86 82 72 72 61 4 43 22 60% partly 80% not possible 14 100%

Figure 3. Application of educational competencies (nurse practitioners)

giving information self-empowerment for professional development

development of teamwork 2 10 competencies structurising the scope of activity 8 implementation of teamwork development of personnel saturation application of innovations flexibility motivating others empowerment of personnel for continuing development evaluation of personnel problems 0% 18

88 15 14 43 48 30 44 74 81 20% possible 40% 60% partly 41 39 12 10 80% not possible 22 19 77 68 35 33 29 17 14 9 100%

Figure 4. Application of managerial and administrational competencies (nurse practitioners)

The deciency in motivating factors in activity environment The factor analysis illuminated the decient factors in order nurses practitioners and executives would be motivated to work in full value (Table I). Correlation analysis highlighted the following nuances: collectively made decisions are correlated with nurses empowerment and autonomy in activity environment; lack of autonomy and empowerment limits the possibilities to make decisions collectively and effectively; dysfunctional the information-sharing mechanism at private health care organization interrupt the collective decision-making process among nurses practitioners and executives too (Table II). Nurse practitioners and executives indicate that methodically prepared meetings increase effectiveness of interpersonal communication and correlates strongly with constructive conict-solving; also the effective interpersonal communication strongly correlates with constructive conict-solving (Table III). Research results show that motivation of nurse practitioners and executives is inuenced by the complex of activity aspects relating to management, psychology, education and sociology. And it is not enough for nurses to perform technical procedures and know pathological processes. Here the capabilities to communicate and
Total variance Cronbach explained (percent) a 0.82 12.5

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Factor title Decient factors as work demotivators

Items Parity collaboration Ethical interpersonal relationships and ethical behavior Expression of positive personal features Recognition of nursing activity Recognition of nurses competence Recognition and respect to nursing as profession

6 0.80 0.77 0.64 0.62 0.59 0.55

Table I. Results of factorial analysis: decient motivating factors

Nurses are not empowered and not autonomous in activity Nurses are not empowered and not autonomous in activity Decisions are not made collectively In organization does not exist mechanism of information-sharing Note: *p # 0.01

Decisions are not made collectively

In organization does not exist mechanism of information-sharing

0.88 * 0.88 * 0.53 * 0.74 *

0.53 * 0.74 * Table II. Results of correlation analysis: motivating factors (1)

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collaborate, plan and delegate, solve the problems and make decisions, teach and conduct research, understand patients individuality and uniqueness in a concrete context, do not ignore the subjective aspects of a person (emotions, feelings, expectations, standpoints and, etc.) are important for nursing personnel in respect to improving their motivation in health care organizations. The improvement of motivation of nurses is stipulated by the elements of professional competence of nurses (knowledge, standpoints, and values), the content of autonomous nursing activity, the possibility to perform professional competence in full value, nurses empowerment and their work status. The interferences of motivation are the following: the content of narrowed nursing activity, which limits the possibilities to perform the competencies of nurses, and the deciency in nurses empowerment from the activity point of view. Nurses motivation is not interfered by the elements of professional competence of nurses and their work status. An issue for further research This study sought to assess the differences in perceptions among nurse practitioners and executives regarding work motivation in the private health care organizations. There is a paucity of literature related to health care workers viewpoints about motivational factors in various health care arenas without differentiation between private and public. With an increased demand for higher productivity, changing health care system and managed health care activity restrictions, it is also important to understand what are the differences of health care workers motives (including nurses too) in respect to type of health care organization. Ineffective collaboration with physicians relates to the downsized work organization and complex deference-dominance physician-nurse relationship; the well-being of nurses depends on being an equal health professional in a comprehensive team that shares knowledge and improves collaborative care of patients (Hertting et al., 2004). The former descriptions of motivation and motivators in health care context with the focus on nursing personnel constitute a developmental continuum of nursing from minimally acceptable levels of competence to excellence. It is argued that the quality of nursing cannot be assessed in terms of performance referenced criteria, but only in terms of the personal qualities displayed in the performance. Thus, the prerequisite to improvement of work motivation in practice may be the improvement of emotional tendencies among nurses (DiCenso et al., 1998). This study demonstrates the importance of analyzing feelings, experiences of nurse practitioners and executives
Methodically prepared meetings of personnel Methodically prepared meetings of personnel Effective interpersonal communication Constructive conict-solving Note: *p # 0.01 Effective interpersonal communication 0.53 * 0.53 * 0.66 * 0.87 * Constructive conict-solving 0.66 * 0.87 *

Table III. Results of correlation analysis: motivating factors (2)

relating to professional hierarchical environment, and the need to support professional assertiveness in relation to superiors and physicians from managerial point of view. It is also important to stress considerations that relate to differences in the age, organizational philosophy and culture, and psychosocial health conditions of health care personnel in private health care organizations. Researchers and practitioners are challenged to examine carefully the role of motivation and its improvement for managerial behaviors of health care workers and explore other factors that may more strongly inuence those behaviors. Although there was a small sample size in this study, the results do point to more similarities than dissimilarities among nurse practitioners and executives. Continued studies regarding the differences between work-setting such as public and private health care organization in respect to motivation improvement is also warranted, due to the preliminary ndings on varying perceptions of motivational constraints. Summary and conclusions It was felt that nurse executives would consider motivation improving factors similarly to nurse practitioners. However, the nurses identify social aspects as motivators due to the caring role. This aspect of work distinguishes health care workers and could have possibly inuenced the nature of motivation. In general, the research results reect the limits of nursing activity: at the institutions of vocational education nurses acquire multidisciplinary competencies, however, they do not have possibilities to apply them in full value in the context of nursing practice. The current nursing activity is oriented to the stereotyped hierarchical obedience to the profession of a physician more than to the development of nursing practice and the autonomy of nurses profession on the basis of multiprofessional collaboration, which is connected to increase of the motivation. Owing to this the outcome is the following: a nurse becomes an obedient performer and his/her mental function is transferred to a higher person in professional hierarchy; the weight of nurses responsibility for the activity outcome does not decrease; the process of vocational and permanent education of nurses becomes detached from the real nursing practice where the educational, practical-experiential and, etc. potential of a nurse is not rare refused. Results showed no statistical differences among nurse practitioners and executives of what motivates them in private health care organization as workplace and illuminated factors that decrease and increase motivation among nurses: . Motivation decreases, when nurses are not empowered and not autonomous in activity; nurses competencies (specic professional and general) are not applied in full value, e.g. managerial, educational, social-psychological, clinical-expertise; decisions are not made collectively; the mechanism of information-sharing is ineffective; meetings of personnel are not structured and not prepared methodically. . Motivation increases when the nurses collaborate with physicians by parity; nursing profession is respected and recognized as autonomous and valued by themselves and other health care specialists; the interpersonal communication is effective and conicts are solved constructively.

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About the authors Zydziunaite Vilma PhD EdSc is an Associated Professor at Kaunas University of Technology, Lithuania. She received her MA EdSc (Vytautas Magnus University, Lithuania); MA Sc in Caring Science/Nursing (Blekinge Institute of Technology, Sweden); BA University Diploma Nurse-Specialist (Kaunas University of Medicine, Lithuania). She has published 32 scientic articles, 1 monograph, 11 study books. Her research interests are teamwork competencies, cross-cultural research, qualitative diagnostics in social, managerial and health research, formation of professional identity and philosophy of a profession in higher education and practical activities, qualitative and quantitative evaluation of personnel. Zydziunaite Vilma is the corresponding author and can be contacted at: vilmzydz@takas.lt Katiliute Egle received PhD EdSc; MA EdSc; BA in Business Administration (Kaunas University of Technology, Lithuania). He is working as a Senior Lecturer at Klaipeda College and Vytautas Magnus University. He has published ten scientic articles. His research interests are educational and social policy, management and human resource management in business, educational and social service and health care organizations. E-mail: eglekatiliute@gmail.com

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