Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia

Abstract

Health worker motivation reflects the interactions between workers and their work environment. Because of the interactive nature of motivation, local organizational and broader sector policies have the potential to affect motivation of health workers, either positively or negatively, and as such to influence health system performance. Yet little is known about the key determinants and outcomes of motivation in developing and transition countries. This exploratory research, unique in its broader study of a whole range of motivational determinants and outcomes, was conducted in two hospitals in Jordan and two in Georgia. Three complementary approaches to data collection were used: (1) a contextual analysis; (2) a qualitative 360-degree assessment; and (3) a quantitative in-depth analysis focused on the individual determinants and outcomes of the worker's motivational process. A wide range of psychometric scales was used to assess personality differences, perceived contextual factors and motivational outcomes (feelings, thoughts and behaviors) on close to 500 employees in each country. Although Jordan and Georgia have very different cultural and socio-economic environments, the results from these two countries exhibited many similarities among key determinants: self-efficacy, pride, management openness, job properties, and values had significant effects on motivational outcomes in both countries. Where results were divergent, differences between the two countries highlight the importance of local culture on motivational issues, and the need to tailor motivational interventions to the specific issues related to particular professional or other groupings in the workforce. While workers themselves state that financial reward is critical for their work satisfaction, the data suggest a number of non-financial interventions that may be more effective means to improve worker motivation. This research highlights the complexity of worker motivation, and the need for a more comprehensive approach to increasing motivation, satisfaction and performance, and for interventions at both organizational and policy levels.

Introduction

Evidence of poor worker motivation can be seen across countries at different levels of development. Motivational issues at work may show themselves in many ways, but common manifestations include: lack of courtesy to patients; tardiness and absenteeism; poor process quality such as failure to conduct proper patient examinations; and failure to treat patients in a timely manner (Gilson, Alilio, & Heggenhougen, 1994; Mutizwa-Mangiza, 1998; Van Lerberghe, Conceição, Van Damme, & Ferrinho, 2002). Yet, health sector performance, and in turn, health outcomes, are critically dependent on worker motivation (Martinez & Martineau, 1998). Health care is highly labor-intensive, and thus, service quality, efficiency, and equity are all directly mediated by workers’ willingness to apply themselves to their tasks.

While worker performance is dependent on, or limited by, resource availability and worker competencies, the presence of these factors is not sufficient in themselves to ensure desired worker performance. Worker performance is also contingent on workers’ willingness to come to work regularly, work diligently, be flexible, and carry out the necessary tasks (Hornby & Sidney, 1988). Health sector policy makers and health facility managers must recognize the importance of work motivation in reaching sector and organization goals, and they must understand the links between their current policies and worker motivation (Van Lerberghe et al., 2002).

Motivation in a work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. It is a set of psychological processes that influences workers’ allocation of personal resources towards those goals, which in turn affect workplace effectiveness and productivity (Kanfer, 1999). Work motivation is not an attribute of the individual or the organization; rather, it results from the transaction between individuals and their work environment (Kanfer, 1990; Mitchell, 1997). Because of this interactive nature of motivation, local organizational and broader sector policies have the potential to affect motivation of health workers, either positively or negatively (Franco, Bennett, & Kanfer, 2002).

Work motivation exists when there is alignment between individual and organizational goals: when achievement of organizational goals is associated with personally desired outcomes, such as a sense of achievement or personal gain. Two interrelated psychological streams operate in the work motivation process (Kanfer, 1999):

• The “will do” component: the extent to which workers adopt organizational goals, which is dependent on the individual's work ethic and the intrinsic and extrinsic rewards emanating from the work.

• The “can do” component: the extent to which workers effectively mobilize their personal resources to achieve joint goals, which is dependent on workers’ perceptions of their competencies and perceptions of availability of appropriate resources and environment.

Determinants of worker motivation can affect one or both of these streams, and lead to the major outcome of the motivational process: worker behavior or performance. Other motivational outcomes include workers’ emotional and cognitive responses to the work context.

Because work motivation is a transactional process between the worker and the work environment, broader organizational and societal factors affect worker motivation. Franco et al. (2002) examined mechanisms through which these broad factors can affect motivation and how health reform can affect these factors and thus motivation. Organizational factors that define the work environment include resource availability and efficiency of processes, human resource management practices, and organizational culture. The organization and the individual worker are also part of a broader society that influences their goals and values through community expectations, peer pressure, and social values. Health policies involving provider payment mechanisms, human resource management, community empowerment, and decentralization have the potential to alter these organizational and societal relationships and can have intended and unintended effects on worker motivation. For example, in Kazakhstan, health sector reforms which emphasized autonomous family practice clinics rearranged the relationships between providers and patients and led to improved provider responsiveness to patient needs (Abzalova, Wickham, Chukmaitov, & Rakhipbekov, 1998). In contrast, in Zambia, decentralization reforms de-linking health staff from the civil service encountered resistance because it appeared to reduce job security and career advancement (Lake, Daura, & Mabandhla, 2000).

Within this larger organizational and societal context, worker motivation is an individual, internal, and unobservable process. The internal motivational process can be visualized as a series of measurable inputs (determinants) that lead to certain measurable motivational outcomes. Individual level determinants can be categorized into: those that relate to individual personality and value systems; those that relate to the individual's perceptions of the work environment; and those factors that are demographic in nature (see Fig. 1). Motivational outcomes can also be grouped into different types of responses: behavioral—what workers do; emotional or affective—what workers feel; and rational or cognitive—what workers think. These motivational outcomes also interact among themselves. While motivational inputs and outcomes at an individual level operate within a broader context, their motivational significance is viewed through the eyes of the health worker. Fig. 1 summarizes the relationships between these various constructs and is based on the vast motivation literature from industrialized countries, as well as the model previously developed by the authors (Franco et al., 2002).

Although the importance of worker motivation is often mentioned, little research has been published on health worker motivation in developing country contexts. Some studies that deserve mention include the study of motivation and performance of health personnel in Benin (Alihonou, Soudé, & Hounye, 1998), and a study on public sector physicians in Malaysia (Sararaks & Jamaluddin, 1999). A few studies have examined the specific issues of worker satisfaction and its relation to retention, especially among nurses (for example, Garcia-Pena, Reyes-Frausto, Reyes-Lagues, & Munoz-Hernandez, 2000; al-Ma’aitah, Cameron, Horsburgh, & Armstrong-Stassen, 1999; Fung-kam, 1998; Ndiwane, 1999). However, no studies have examined a broad range of motivational determinants and their relationship to a variety of motivational outcomes.

This exploratory study sought to identify which motivational determinants appear important in developing and transition country public sector health care settings and to ascertain the possibility of using methodologies developed for industrialized countries. This study aimed to identify the kinds of interventions and strategies that should be built into health care reforms to facilitate health worker motivation, and thus improve both health sector performance and health outcomes. Drawing upon the conceptual framework (Fig. 1), the key research question for this study was: which motivational constructs are relevant in particular developing and transition country healthcare settings and how do demographic factors (such as profession, gender, age, and type of hospital) affect them?

The two countries chosen for this study (Jordan and Georgia) provided two very distinct contexts for studying worker motivation. Thus, a brief description of the broader environment affecting worker motivation will be important for interpretation of the results.

At the time of the study (1999–2000), both Jordan and Georgia were experiencing widespread economic difficulties and declining real values of salaries, although the trends were more acute in Georgia. Since the collapse of the Soviet Union, the Republic of Georgia has gone through rapid, dynamic, and often poorly planned reforms at the sector level (Gzirishvili & Mataradze, 1999). Although Jordan has planned many changes or developments for improving health sector functioning, few reforms were beyond the conceptualization stage, and health workers have been operating in a much more stable environment.

The Jordanian and Georgian health sectors differed with respect to supply of human and physical resources. The Georgian health sector, like most of the former Soviet Union, has an oversupply of both physicians and hospital beds (Atun, Gamkrelidze, & Vasadze, 2000). In contrast, Jordan has shortages in the public sector of physicians, nurses, and other critical health professionals, and bed-occupancy rates are higher than in Georgia (World Bank, 1996). These differences have a significant effect on workloads and work cultures within the facilities.

In both countries, average income levels are quite low. However, Jordanian formal salaries are based on fixed annual amounts and make up the bulk of income for public sector providers in Jordan. In Georgia, salaries are extremely low: formal salaries for physicians and nurses are calculated on a fee-for-service basis (with no account for seniority or experience), and hospital staff in Georgia depend on informal payments for about half their total income (GORBI, 2000).