Improving Motivation

Improving motivation amonghealth care workers in private

health care organizationsA perspective of nursing personnel

Zydziunaite VilmaKaunas University of Technology, Kaunas, Lithuania, and

Katiliute EgleVytautas Magnus University, Kaunas, Lithuania

Abstract

Purpose – The study aims to explore the experiences of nursing personnel in private health careorganizations in Lithuania, in terms of their work motivation and satisfaction, promotion and quittingthe job, interpersonal interaction at work and to identify areas for sustainable improvement to thehealth care services they provide.

Design/methodology/approach – The research problem includes the following questions. What isthe attitude of nursing personnel to the existing elements of motivation in private health careorganizations? What organizational tools should be developed in order to improve the motivation ofnursing personnel? The sample consists of 237 registered nurses practitioners and 30 nurses’managers working in private health care sector. Methods: data selection: questioning survey; dataanalysis: 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 aof every part ranges from 0.68 to 0.85.

Findings – Results showed no statistical differences among nurse practitioners and executives ofwhat motivates them in private health care organization as workplace and illuminated factors thatdecrease and increase motivation among nurses. Motivation decreases, when nurses are notempowered not autonomous in activity; nurses’ competencies (specific professional and general) arenot applied in full value, e.g. managerial, educational, social-psychological, clinical/expertise; decisionsare not made collectively; in organization does not exist mechanism of information-sharing; meetingsof personnel are not prepared methodically. Motivation increases when the nurses collaborate withphysicians by parity; nursing profession is respected and recognized as autonomous and valued bythemselves and other health care specialists; the interpersonal communication is effective and conflictsare solved constructively.

Research limitations/implications – A major weakness is that the characteristics of the presentsample may limit the generalizability of the results. The major implication is that the paper supportsthe prediction for characteristics of motivation among health care workers in private health careorganizations with perspective of nursing personnel.

Originality/value – The paper examines in a private health care sector the factors that increaseand/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 personnelThe question of how to improve the motivation of personnel among health careworkers is quite properly perceived to be at the heart of the contemporary

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Motivationamong healthcare workers

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Baltic Journal of ManagementVol. 2 No. 2, 2007

pp. 213-224q Emerald Group Publishing Limited

1746-5265DOI 10.1108/17465260710751008

health care management debate (Glen, 1998; Chiu, 2005). Managerial concerns relatedto employee motivation are not new (Herzberg et al., 1959; Vroom, 1964), but questionsconcerning motivational incentives and employees’ perceptions of what motivatesthem in the workplace continue to be discussed and analyzed. Motivation is afrequently cited rationale underlying the adoption and maintenance of healthbehaviors in research and practice (Carter and Kulbok, 2002; Grafham et al., 2004).Motivation is complex and multidimensional, and clearer definitions for motivation areneeded. Researchers and practitioners are challenged to examine carefully the role ofmotivation for health behaviors and explore other factors that may more stronglyinfluence behaviors of health care workers.

Many contemporary authors have defined motivation. Kreitner (1995) and Grafhamet al. (2004) refer to motivation as a psychological process that gives direction tobehavior; Higgins (1994) and Begat et al. (2005) define motivation as an internal drivethat 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 withmanagement issues related to organizational performance. They define motivation as a“state of mind, desire, energy, or interest that translates into action”. This action isviewed as work performance. The belief is that this performance can be influencedwhen employee motivation is influenced. Employee motivation can be influenced dueto motivation being a flexible state of mind.

The present era of cost containment pressures means that nurse executives need toensure that nurses have a work environment with the characteristics of work knownto be linked to job satisfaction, motivation and good outcomes, e.g.: the key toimprovement in health care practice may be the improvement of relationship betweenmotivational tendencies, professional development and personal development amonghealth care professionals (Glen, 1998; Iley, 2004); the autonomy, communication,adequate time for patient care (Aronowitz and Munzert, 2006) and the degree ofenvironmental uncertainty contributed to job satisfaction and work motivation ofnursing personnel (Freeman and O’Brien-Pallas, 1998; Edgar, 1999; Oweis, 2005); thehelping pathways such as reward seeking, altruism, and punishment-avoidance arethe work motives for caregivers (Smith et al., 2001); general job satisfaction, general jobhappiness, satisfaction with salary and promotion, institution, educational backgroundare proved to be significant predictors of nurses’ decrease of work motivation (Tzeng,2002; Davidhizar, 2004). Articles on improvement of motivation in private health caresector are limited. Among the health professional journals, nursing literature has themost on managerial aspects, motivation and job satisfaction without differentiation topublic or private health care sector. Nevertheless, in some articles is presented suchkind of research-based information.

Munro (1983) indicated that working conditions, status and security may operate asmotivators within nursing profession; Rantz et al. (1996) identified the achievement,recognition, work itself, responsibility and advancement as motivators of nurses;Smith (2000) described a study on job satisfaction that was done with occupationaltherapists and the job characteristics of feedback on the job, task significance,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

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could increase or diminish the intrinsic work motivation of nurses. Employeeempowerment may be influenced by the perception that the organization cares aboutits employees’ well-being and that their work is valued. Morrison et al. (1997) andAmundsen, Corey (2000) indicate that the leadership style and empowerment influencejob satisfaction and work motivation among health care workers. Nevertheless, theemotional intelligence of nurse executives and nurses’ practitioners is prerequisite fortheir work motivation (Cadman and Brewer, 2001).

The research studies of McNeese-Smith (1998) and Foster (2000) examined therelationships among nurse managers’ motivation for power, achievement andaffiliation, managerial leadership behaviors, staff nurse outcomes of job satisfaction,productivity and organizational commitment and patient satisfaction. Results showedthat managerial motivation for power is negatively correlated with manager use ofleadership behaviors and staff nurse job satisfaction but positively correlated withpatient satisfaction. Managerial motivation for achievement is positively correlatedwith 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 tostaff nurses’ self-efficacy development (George et al., 2002; Iley, 2004). Authors alsoindicate that the professional nursing practice autonomy, leadership behaviorsimproves the nurses’ work motivation and patient outcomes too.

The studies of Hertting et al. (2004) and Secrest et al. (2005) demonstrate theimportance of analyzing feelings relating to professional ambiguity and stress.Also they give emphasis to considerations relating to differences in the age, carephilosophy, and psychosocial health conditions of nurses. The concurrence of“ever-growing job demands” and “work going unrewarded” contributes to a feeling ofbeing taken advantage of by the employer. The well-being of nurses and improvementof work motivation depends on being an equal/parallel health professional in acomprehensive team that shares knowledge and improves collaborative care ofpatients and a consciously formulated nursing philosophy at health care organization.But there is no differences in nurses’ job satisfaction or work motivation in differentorganizational 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 nursingactions, individual accountability for clinical outcomes, and regular performancefeedback from managers and factors motivating the nurses’ work motivation.

MethodologyThe multidimensional concept of motivation has been noted in the literature as difficultto define due to an inability to directly observe it. By observing one’s behavior,conclusions are typically drawn regarding motivation. The assumption is made thatan inner drive directs and maintains motivation that results in certain behaviors.With this “inner drive” nature of motivation, it may be best measured throughself-reflection of a variety of situations related to what motivates or what constrainsone from being motivated in the workplace. For the purposes of this study motivationis defined as the inner force that drives the nurse to accomplish personal andorganizational goals. The various factors associated with improvement of motivation,


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including application of competencies, activity environment, communication andcollaboration, responsibility, results and encouragement, autonomy, self-realization,activity purposefulness in the study were categorized as motivators.

Research designA questionnaire was given to 237 registered nurse practitioners and 30 nurseexecutives working in private health care sector. Returning quota of questionnaires is97 percent. Sampling was non-probability, purposeful. Research participants werefrom five (biggest) towns in order to represent all the geographical areas of Lithuania.

InstrumentsResearch instrument consisted of 99 closed-ended items divided into 11 evaluationparts:

(1) first 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-administrationalcompetencies;

(5) fifth 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 reflects

barriers to motivation. The repeated statement on the improvement of work motivationquestionnaire states “I believe my professional ‘I’ and overall motivation would suffermost in a job situation wherein . . . ” This may be interpreted as a constraint due to theindication of something limiting motivation on the job. The respondent thendistributed five points between the two responses that followed. The two responsesreflect external (activity environment, communication and collaboration, results andencouragement, autonomy, activity purposefulness) and internal (self-realization,responsibility, application of competencies) motivators, respectively. The numbersgiven 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 identified as a notable. Reliability for the entire questionnaire has beenestablished at 0.70. Construct validity is high, yielding a correlation of 0.82.

MethodsData selection: questioning survey. Data analysis: descriptive statistics, correlationand factor analysis (using SPSS for Windows 12.0).

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Findings of the studyApplication of social-psychological competenciesIn private health care organizations nurses practitioners are not treated as equalpartners in team-working, have no possibilities to show the professional confidenceand to manage the conflicts autonomously. But nurse practitioners are helpful, open,empathic, patient and tolerant (Figure 1).

Nurse executives realize the collaboration and conflict management competencies infull value, but they lack empathy and tolerance.

Application of clinical-expertise competenciesThe nurse practitioners indicate that they perform effectively the assessment ofpatient’s state, but poorly realize competencies of reflection on activity, evaluationof activity mistakes and concrete work situation, and minimization of patient’s stress(Figure 2).

Nurse executives note that they perform efficiently competencies ofproblem-solving and evaluation of activity mistakes and results.

Figure 2.Application of

clinical-expertisecompetencies (nurse

practitioners)

88

34

73

52

64

31

31

11

13

8

60

14

34

20

20

20

10

3

4

6

13

14

16

49

49

79

84

0% 20% 40% 60% 80% 100%

assessing patient's state

evaluating activity results and mistakes

collecting information

problem solving

analysing

evaluating situation

releasing the stress of the patient

diagnosing activity mistakes

reflecting activity

possible partly not possible

Figure 1.Application of

social-psychologicalcompetencies (nurse

practitioners)

97

88

3

10

31

20

33

34

31

12

20

2

14

16

27

32

47

56

71

0% 20% 40% 60% 80% 100%

patiency

tolerance

listening

empathy

openess

interpersonal help

conflict management

confidence

collaborate with physicians by parity


9

32

22

34

40

64

55

0


217

Application of educational competenciesNurse executives do not perform the following competencies: learning in teams,patients’ education and knowledge utilization. Nurse practitioners the most effectivelyrealize the self-empowerment for professional development (Figure 3).

Application of managerial and administrational competenciesNurse practitioners most successfully realize the competencies of personnelempowerment 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 ofteamwork competencies, structuring of activity scope and implementation ofteamwork in full value.

In presentation the results of factorial and correlation analyses the data selectedfrom nurse practitioners and executives were integrated.

Figure 4.Application of managerialand administrationalcompetencies (nursepractitioners)

81

74

44

30

48

43

18

8

2

10

12

39

41

19

22

14

15

10

9

14

17

29

33

35

68

77

88

0% 20% 40% 60% 80% 100%

evaluation of personnel problems

empowerment of personnel forcontinuing development

motivating others

flexibility

application of innovations

development of personnel saturation

implementation of teamwork

structurising the scope of activity

development of teamworkcompetencies


Figure 3.Application of educationalcompetencies (nursepractitioners)

64

53

26

18

7

9

3

2

0

22

4

13

10

21

9

11

3

3

14

43

61

72

72

82

86

95

97

self-empowerment for professionaldevelopment

giving information

knowledge utilization

counseling (patients and colleagues)

patient's education

education of colleagues

learning by collaboration

preparing teaching material

learning in teams


0% 20% 40% 60% 80% 100%

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The “deficiency” in motivating factors in activity environmentThe factor analysis illuminated the “deficient” factors in order nurses practitioners andexecutives would be motivated to work in full value (Table I).

Correlation analysis highlighted the following nuances: collectively made decisionsare correlated with nurses’ empowerment and autonomy in activity environment; lackof autonomy and empowerment limits the possibilities to make decisions collectivelyand effectively; dysfunctional the information-sharing mechanism at private healthcare organization interrupt the collective decision-making process among nursespractitioners and executives too (Table II).

Nurse practitioners and executives indicate that methodically prepared meetingsincrease effectiveness of interpersonal communication and correlates strongly withconstructive conflict-solving; also the effective interpersonal communication stronglycorrelates with constructive conflict-solving (Table III).

Research results show that motivation of nurse practitioners and executives isinfluenced by the complex of activity aspects relating to management, psychology,education and sociology. And it is not enough for nurses to perform technicalprocedures and know pathological processes. Here the capabilities to communicate and

Nurses are notempowered and not

autonomous in activityDecisions are notmade collectively

In organization does notexist mechanism ofinformation-sharing

Nurses are notempowered and notautonomous in activity 0.88 * 0.53 *

Decisions are not madecollectively 0.88 * 0.74 *

In organization does notexist mechanism ofinformation-sharing 0.53 * 0.74 *

Note: *p # 0.01

Table II.Results of correlationanalysis: motivating

factors (1)

Factor title Items N LCronbach

aTotal variance

explained (percent)

“Deficient“ factors as Parity collaboration 6 0.80 0.82 12.5work demotivators Ethical interpersonal

relationships and ethicalbehavior 0.77Expression of positivepersonal features 0.64Recognition of nursingactivity 0.62Recognition of nursescompetence 0.59Recognition and respect tonursing as profession 0.55

Table I.Results of factorial

analysis: “deficient“motivating factors


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collaborate, plan and delegate, solve the problems and make decisions, teachand conduct research, understand patient’s individuality and uniqueness in a concretecontext, do not ignore the subjective aspects of a person (emotions, feelings,expectations, standpoints and, etc.) are important for nursing personnel in respect toimproving their motivation in health care organizations.

The improvement of motivation of nurses is stipulated by the elements ofprofessional competence of nurses (knowledge, standpoints, and values), the content ofautonomous nursing activity, the possibility to perform professional competence in fullvalue, nurses’ empowerment and their work status. The interferences of motivation arethe following: the content of “narrowed” nursing activity, which limits the possibilitiesto perform the competencies of nurses, and the deficiency in nurses’ empowermentfrom the activity point of view. Nurses’ motivation is not interfered by the elements ofprofessional competence of nurses and their work status.

An issue for further researchThis study sought to assess the differences in perceptions among nurse practitionersand executives regarding work motivation in the private health care organizations.There is a paucity of literature related to health care workers’ viewpoints aboutmotivational factors in various health care arenas without differentiation betweenprivate and public. With an increased demand for higher productivity, changing healthcare system and managed health care activity restrictions, it is also important tounderstand what are the differences of health care workers’ motives (including nursestoo) in respect to type of health care organization.

Ineffective collaboration with physicians relates to the downsized workorganization and complex “deference-dominance” physician-nurse relationship; thewell-being of nurses depends on being an equal health professional in a comprehensiveteam that shares knowledge and improves collaborative care of patients (Hertting et al.,2004). The former descriptions of motivation and motivators in health care contextwith the focus on nursing personnel constitute a developmental continuum of nursingfrom minimally acceptable levels of competence to excellence. It is argued that thequality of nursing cannot be assessed in terms of performance referenced criteria,but only in terms of the personal qualities displayed in the performance. Thus, theprerequisite to improvement of work motivation in practice may be the improvement ofemotional tendencies among nurses (DiCenso et al., 1998). This study demonstrates theimportance of analyzing feelings, experiences of nurse practitioners and executives

Methodically preparedmeetings of personnel

Effective interpersonalcommunication

Constructiveconflict-solving

Methodically preparedmeetings of personnel 0.53 * 0.66 *

Effective interpersonalcommunication 0.53 * 0.87 *

Constructiveconflict-solving 0.66 * 0.87 *

Note: *p # 0.01

Table III.Results of correlationanalysis: motivatingfactors (2)

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relating to professional hierarchical environment, and the need to support professionalassertiveness 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 healthcare personnel in private health care organizations.

Researchers and practitioners are challenged to examine carefully the role ofmotivation and its improvement for managerial behaviors of health care workersand explore other factors that may more strongly influence those behaviors.Although there was a small sample size in this study, the results do point to moresimilarities than dissimilarities among nurse practitioners and executives.Continued studies regarding the differences between work-setting such as publicand private health care organization in respect to motivation improvement is alsowarranted, due to the preliminary findings on varying perceptions of motivationalconstraints.

Summary and conclusionsIt was felt that nurse executives would consider motivation improving factorssimilarly to nurse practitioners. However, the nurses identify social aspects asmotivators due to the caring role. This aspect of work distinguishes health careworkers and could have possibly influenced the nature of motivation. In general, theresearch results reflect the limits of nursing activity: at the institutions of vocationaleducation nurses acquire multidisciplinary competencies, however, they do not havepossibilities to apply them in full value in the context of nursing practice. Thecurrent nursing activity is oriented to the stereotyped hierarchical obedience to theprofession of a physician more than to the development of nursing practice andthe autonomy of nurse’s profession on the basis of multiprofessional collaboration,which is connected to increase of the motivation. Owing to this the outcome is thefollowing: a nurse becomes an obedient performer and his/her mental function “istransferred” to a “higher” person in professional hierarchy; the “weight” of nurse’sresponsibility for the activity outcome does not decrease; the process of vocationaland permanent education of nurses becomes detached from the “real” nursingpractice where the educational, practical-experiential and, etc. potential of a nurse isnot rare refused.

Results showed no statistical differences among nurse practitioners and executivesof what motivates them in private health care organization as workplace andilluminated factors that decrease and increase motivation among nurses:

. Motivation decreases, when nurses are not empowered and not autonomous inactivity; nurses’ competencies (specific professional and general) are not appliedin full value, e.g. managerial, educational, social-psychological, clinical-expertise;decisions are not made collectively; the mechanism of information-sharing isineffective; meetings of personnel are not structured and not preparedmethodically.

. Motivation increases when the nurses collaborate with physicians by parity;nursing profession is respected and recognized as autonomous and valued bythemselves and other health care specialists; the interpersonal communication iseffective and conflicts are solved constructively.


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About the authorsZydziunaite 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 CaringScience/Nursing (Blekinge Institute of Technology, Sweden); BA University DiplomaNurse-Specialist (Kaunas University of Medicine, Lithuania). She has published 32 scientificarticles, 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 andpractical activities, qualitative and quantitative evaluation of personnel. Zydziunaite Vilma is thecorresponding author and can be contacted at: [email protected]

Katiliute Egle received PhD EdSc; MA EdSc; BA in Business Administration (KaunasUniversity of Technology, Lithuania). He is working as a Senior Lecturer at Klaipeda College andVytautas Magnus University. He has published ten scientific articles. His research interests areeducational and social policy, management and human resource management in business,educational and social service and health care organizations. E-mail: [email protected]

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