1) To review the literature in order to understand the relationship between staff motivation and performance (including low absenteeism, reduced staff turnover etc.),and how increased empowerment of staff can improve staff motivation(including the comparison with the relevant motivating factors).
2) To review the literature in order to identify what is considered to be good practice in terms of both empowerment and recognition and to compare this with the current practice at the Bombay Hospital
THE RELATIONSHIP BETWEEN STAFF MOTIVATION AND INDIVIDUAL PERFORMANCE
Shortages can be a symptom of demotivation, poor management and lack of organizational support (Zurn et al., 2005). Shortages are resulting in heavy workload, which is a precursor to job stress, and burnout, which have also been linked to low job motivation. Nurses’ job motivation is an elusive concept, which is defined within its extrinsic and intrinsic values (Cowin, 2002). Extrinsic values encompass the tangible aspects of the job including wages, benefits and bonuses, whereas intrinsic values include status, recognition, personal and professional development opportunities, and other similar factors (Cowin, 2002). Reasons for nurse demotivation have been well documented in the nursing literature. Such reasons include lack of involvement in decision-making, poor relationship with management, low salaries and poor benefits, lack of job security, poor recognition and lack of flexibility in scheduling (Albaugh,2003). Nurse demotivation has been also linked to emotional exhaustion and burnout,
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Which can affect patient outcomes (Aiken et al., 1997). Furthermore Shields & Ward (2001) and Tzeng (2002) has also stated that improper motivation is a primary predictor of nurses’ intent to leave (Shields & Ward, 2001; Tzeng, 2002). A study conducted in the United States presented evidence showing that demotivated nurses were 65% more likely to have intent to leave compared to the motivated counterparts (Shields & Ward, 2001). Other predictors of intent to leave vary from other motivation factors like low salaries and fringe benefits, inflexible work schedule (Coomber & Barriball, 2007; Hayes et al, 2006), career advancement prospects (Tzeng, 2002, Rambur et al., 2003), in addition to poor management and job stress (Rambur et al., 2003). Nurses’ turnover is linked to situational factors (Larrabee et al., 2003) such as low levels of motivation (Tzeng, 2002). It is worth noting that improper motivation has also been found to be a better predictor of intent to leave as compared to the availability of other employment opportunities (Shields & Ward, 2001; Purani & Sahadev 2007). A study by El-Jardali et al. (2007) also found a negative correlation between motivation and intention to leave in Lebanese nurses. Their study’s main objective was to examine the impact of motivation as a predictor variable on intention to leave used as dependent variable in the study. The finding of the study reveals that the main cause of the dissatisfaction and hence intention to leave was negatively associated with hospital’s motivation schemes such as compensation and incentives (extrinsic rewards). Purani and Sahadev (2007) used motivation with multi-faceted construct as predictor variable and examine its impact on intention to leave among the nurses in India. Assuming one of the role as “interaction and communication” with clients and patient of both profession is common, their study also used experience as moderating variables to examine how working experience could affect motivation and intention to leave relationship. Purani and Sahadev (2007) found that employees with long stay at workplace had higher level of motivation and would not incline to quit. Their finding also suggested that motivation and intention to leave relationship framework must also have other demographic variables consideration into the model of motivation and intention to leave. Pearson and Chong (1997) also examined the impact of job content and job information on motivation among Malaysian nurses in large public sector hospital. They found that job information is stronger predictor to nurses motivation and therefore argued that intrinsic factors such as job information and organization commitment also influence nurses motivation. However, they did recommend that motivation with information cues available to nurses are crucial to determine nurses’ motivation which may lead to intent to leave or higher job burnout, if not available. Tzeng (2002) examined the impact of working motivational factors as well as job satisfaction factors as independent variables on nurse’s intention to leave in cross-sectional study in Taiwan. He found that low levels of motivation, emotional exhaustion and burnout and to the poor social image of the nursing profession influenced nurse’s intention to leave in Taiwan’s hospitals. This study therefore, suggested that motivation is a multi-faceted construct and should have both intrinsic as well as extrinsic factors to measure job satisfaction (Tzeng, 2002).
HOW MOTIVATION AFFECTS EMPLOYEE PERFORMANCE
The extent to which employees are motivated in their work depends on how well those employees are able to provide output in their job. Motivation is expected to have a positive effect on quality performance. Employees who are characterized by a high level of motivation show a higher work and life satisfaction. Having a high level of motivation is therefore in itself valuable for employees and a decrease in motivation might affect employees negatively. The motivation leads to high level of initiative and creativity from the employee and where monitoring is difficult, motivation is therefore extremely important for ensuring high quality performance. In Armco Health Center, the quality of employee performance is measured by three individual measures of employee performance. The first measure of the individual performance items is a self-rating measure of employee performance through a program called SAP. The performance of the employee asks to indicate eight-points scale how well the employee is doing the job. The second measure of the performance of the Armco Health Center is the extent to which the nurses are willing to conduct tasks that are not part of their job description. The employees are asked to report on the SAP about their willingness to perform additional tasks that are not expected from them regularly and to think constructively about how the organization they work for could be proved. Last item that measure the performance of the nurses are the number of days they were absent.
EMPOWERMENT AND STAFF MOTIVATION
Nursing is increasingly broad in scope and encompasses an ever widening range of work behaviors and role responsibilities. However, they work within a climate of uncertainty and disempowerment along with high organizational demands placing them under considerable stress (1,2). This condition threatens both physical and emotional wellbeing of nurses and the profession itself and may results to low nurses’ commitment which in turn may contribute to disengagement or withdrawal of nurses from their organizations (3,4). Consequently, threatens organizational functioning and the quality care, since low nurses commitment leads to absenteeism or poor performance (5). However, the nurses low commitment is being a problem in many countries, Aiken et al(6) have cautioned that the health care workforce faces the serious risk of losing one in five registered nurse for reasons other than retirement. Supportively, several other studies revealed that the turnover rate for hospital registered nurse is among the highest rates found for professional and technical occupational groups (7,8). In addition, in 2002 the Joint Commission on Accreditation of Health Care Organizations (JCAHO) recorded that current annual registered nurse turnover rates range from 18% to 26% (9). Moreover, Victorian Governmental Department of Human Services Research suggests that at low levels of job satisfaction and organizational commitment, retention of nursing staff is difficult and this in turn increases absenteeism (10).
The Kingdom of Saudi Arabia, like many other countries is also suffering from nursing low commitment which evidenced by registered nurses’ high turnover rate and resignation(11). However, some national studies and articles highlighted that governmental sectors in Riyadh city were suffering for many years from high turnover rate of nurses that reached to 70% in some hospitals and resulted in high nurses shortage (12,13) . Along with working condition, salary, nursing disempowerment and uncertainty being cited to explain why the nurses exhibit poor work performance or uncommitted to their organization. In a research conducted by Attree (17)
that studies the relationship between nurses’ perception regarding their control and governance , revealed that registered nurse were dissatisfied with their governance, perceived lack of control over their everyday practice and commented on a popular perception that they had become disempowered , lacked influence and asserted that they have fairly little power. It’s the managers and physicians who have the power, not nurses. Both managers and physicians decided, told and
expected from the nurse to just get on with it, without discussion, or negotiation. As Salvage (18), nurses may see themselves as skilled practitioners, but the public still clings to its old image of the nurse as the doctor’s handmaiden. This indicates that nurses are not powerless due to lack in competence, motivation, and/or information, but because lack of awareness and enabling system and structure. Foser and Hoggett (19) termed this situation as a ‘Do more with less culture’ where rhetoric is designed to empower the exhausted workers by emphasizing their commitment to organizational goals . However, disparity between the nurses’ desired and perceived autonomy and control over daily job activities interferes with nurses’ attempts to perform according to their expectations as professionals and may contribute to disengagement and withdrawal from the profession of nursing (17). Parallel to this is the national view of nursing in Saudi culture. Abu- Zinada (11,20) stated in many articles that the nurses were disempowered, and have a feeling of uncertainty. In contrast, she saw that the nurse has the right to make decisions that are separate of the physician’ ones. Moreover, Al-morshed (21) considered that the nurses were not assistants to the physician or that their role is limited to giving injection or helping a patient, since the nursing is a science before everything. Thus, creating conditions that foster a sense of empowerment in healthcare settings are critical to both employee wellbeing and organizational success(22) . For employee well-being, empowerment offers opportunities for learning, development, and playing a more active role in operational decisions through the personal development and involvement in decision making. As a result, employees can sense their feelings of self-worth, meaningfulness, job satisfaction and morale that result from their contributions and control or autonomy over their work. Additionally, empowerment is essential for enhancing nurses’ role, strengthening the professional image, and continuously improving the healthcare system. It allows the nurses to perform in a professional manner by being more autonomous, responsible and participative (23).
For organizational success, many hospitals uses the concept of empowerment as a retention strategies to improve nurses commitment by fostering the desire not to leave the organization for selfish interests or marginal gains, and increase willingness to work by making personal sacrifice, performing beyond normal expectations , endure difficult times with an organization and increasing acceptance of organization’s values and goals . As a consequence, nurses will be less burned-out and more engaged in their work and will contribute to organizational effectiveness (24). Although, the concept of empowerment is frequently used in health services and in nursing ,particularly in relation to the quality of care, since the mission of nursing is to provide safe and quality nursing care thereby enabling patients to achieve their maximum level of wellness(25). Also empowerment play a significant role in the management of job stress and job satisfaction as well as in nurse attraction and retention ( 26). Hence, creating healthy work conditions that empowered nurses and provide freedom to act according to their expectation as a professional, may be a fruitful strategy for nurse managers and administrators to retain nurses who currently work by promoting their commitment to the organization, especially in a critical care settings.
Nowadays, many seek power but few possess it. Nurses are not exception (Marquis and Huston, 2000). In health care settings, an unequal power base exists among administrator, physicians, and nurses as a result of the competing goals of administration and the coexistence of multiple lines of authority (Sabiston and Laschinger, 1995). The rigidity of hierarchical rule-bound structures has been specifically blamed for nurses’ inability to sufficiently control the content of their practice (Laschinger and Havens, 1996). Kanter (1993) proposed that an individual’s effectiveness on the job is influenced largely by organizational aspects of the work environment.
This author identified power and access to opportunities to learn and grow, as structural determinants affecting the behavior of the individual. This power is derived from the ability to mobilize information, support, and resources necessary for getting the job done. Access to these empowering structures is influenced by the degree of formal and informal power an employee has in the organization (Kanter,1993). Formal power evolves from having a defined job that affords flexibility, visibility and centrality to organizational purpose and goals whereas informal power is determined by the extent of employee’s networks and alliances with sponsors, peers, and subordinates within the organization. Access to these empowering structures has a positive impact on employees, resulting in increase in their job satisfaction, level of organizational commitment and feelings of autonomy. Consequently, employees are more productive and effective in meeting organizational goals (Dutcher and Adams, 1994; Laschinger et. al., 1999). Nurses’ autonomy or control over work was seriously limited by unequal power relationships with medical staff, which enhanced physician power and restricted the nurses’ freedom, and consequently hindered their empowerment (McParland et al., 2000). To achieve excellence in nursing requires empowered staff nurses in order to be effective in their roles, and to be more autonomous (Marquis and Huston, 2000). Nurses who perceive them to be empowered are more likely to enhance client care through more effective work practice. Thus by providing the sources of job-related empowerment and autonomy, work methods and outcomes could be improved (Kanter, 1993; Sabiston and Laschinger, 1995).
EMPOWERMENT IMPROVES MOTIVATION
Empowerment. Thomas and Velthouse (1990) define empowerment as personal power that flows from professional growth, which is correlated with job satisfaction. Klakovich (1995) further states that the “empowerment of nursing staff may be the critical variable in achieving positive organizational outcomes while maintaining the caring values of the nursing profession” Klakovich (1996) defines three dimensions of empowerment as reciprocity, synergy, and ownership. Empowerment is a reciprocal leader-follower relationship that advances and aligns strategies, both organizational and individual (Klakovich, 1995). The Reciprocal Empowerment Scale tool reports in three subscales: reciprocity and synergy sub-scales represent the interactive leader/follower process; the ownership subscale represents the outcomes . Reciprocity involves a leadership behavior pattern of sharing power, support and information. Empowerment Research has shown correlations between nursing leadership job satisfaction and empowerment (Laschinger et al., 2003; Mrayyan, 2004). In recent years, the idea of empowerment has become popular in the nursing literature (Kluska et al., 2000; Laschinger & Finegan, 2005). The review of the literature reveals empowerment being used in various contexts; such as, mental health, chronic care, and health promotion (Dahlgaard & Dahlgaard, (2003), Paterson(2001) . In these contexts, the concept of empowerment incorporates positive and respectful relationships through constant dialog (Ellefsen & Hamilton, (2000)& Prybil( 2003). Morrison, Jones, and Fuller (1997) performed a non-experimental descriptive study that explored the effects of leadership style and empowerment on nursing job satisfaction. The participants included various nursing personnel, such as nurse managers, nursing assistants, nursing clinical leaders, licensed practical nurses and staff nurses. The researchers examined how staff nurses perceived empowerment The researchers results in their variance analysis indicated a statistically significant difference in empowerment among different job classifications within the organization Empowerment accounted for more variance with job satisfaction for licensed personnel than for unlicensed personnel, as well as, for differing by type of satisfaction. The researchers’ findings indicate the importance of empowerment to staff nurse job satisfaction. They also show the contribution of empowerment to job motivation and how they vary by personnel. This study gives reason for performing this research study that examined the relationship of nurse empowerment and motivation
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Furthermore, studies have shown that Indian nurses had a moderate empowerment level and their actual work empowerment perception was significantly lower than their expectation (Huang, Lin, Hsu, Chen, & Huang, 2003). The findings also showed that nurses had the lowest score on participation in decision making. Researchers pointed out that the nursing leaders tended to use authority and might only consult several members’ opinions for decision making. The opportunity for nurses to participate in decision making is limited. As such, frontline nurses might think decision making is the manager’s responsibility, not theirs (Mok & Au-Yeung, 2002).
Participation can be seen as the highest level of empowerment. Nurses’ level of participation in decision making (PDM) can be used as an important indicator of empowerment. In western health care system, it has been found that the area where nurses prefer to be involved in decision-making is more related to the context of nursing practice, such as nursing unit operation (Blegen et al., 1993). Yet, in Indian nurses’ PDM is still not well studied. The extent to which nurses prefer to be or are actually involved in decision making is still not clear. Laschinger and Finegan (2005) surveyed 273 medical, surgical and critical care nurses concluding that structural empowerment had a direct effect on organizational trust and respect, job motivation and commitment. An important addition to the understanding of empowerment in nursing education was another finding that empowerment increased motivation level of the nurses (Falk-Raphael, Chinn, Anderson, Laschinger, & Rubotzky, 2004)
Work empowerment has been linked to many other important organizational outcomes, such as job motivation, organizational commitment, lower levels of job stress and empowering leader behaviors (Spence-Laschinger, & Tuer-Hodes, 2003). Hollinger-Smith and Ortigara (2004) stated that nurses’ perceptions of work empowerment are related to commitment to and trust in the organization, autonomy, participation in organizational decision-making, and job motivation. Increased autonomy and work motivation have been directly linked to nurse retention and increased patient satisfaction (Hollinger-Smith & Ortigara, 2004). Empowering work environments can also influence nurses’ ability to practice in a professional manner, ensuring excellent patient care and positive organizational outcomes. Organizational changes have a direct effect on the work environment and may contribute to higher rates of demotivation, burnout and absenteeism among staff (Kuokkanen, Savikko & Doran, 2007). Factors of empowerment can also provide a way to measure the effects of organizational changes (Kuokkanen et al., 2007).
To achieve excellence in nursing requires empowered staff nurses in order to be effective in their roles, and to be more autonomous (Marquis and Huston, 2000). Nurses who perceive them to be empowered are more likely to enhance patient care through more effective work practice. Thus by providing the sources of job-related empowerment and autonomy, work methods and outcomes could be improved (Kanter, 1993; Sabistonand Laschinger, 1995). In Sochalski’s (2002) survey of nurse empowerment , it was found that 1 out of 3 staff nurse participants (manager and staff level) were dissatisfied and hence demotivated in their job. Increasing job satisfaction, as it positively correlates with empowerment and organizational commitment, is a strategy to help retain employees (Laschinger, Finegan, Shamian, & Casier, 2000). As patient care becomes more technologically advanced and complex, (requiring greater experience on the part of nursing staff to perform the job correctly), workplace stability and autonomy become invaluable in a hospital setting (Laschinger et al,2000.). Many researchers have concluded that building collaborative decision making teams will empower both nursing and managerial staff; which boosts morale and work performance (Cowin, 2002 & Kluska et al., 2004). Ellefsen and Hamilton (2000) concluded that nurse empowerment encourages nurses in management positions to perform their duties efficiently and with confidence and competence. Research suggests when hospital leadership encourages subordinate empowerment; there is a direct link to increased subordinate job satisfaction and motivation (Laschinger, Finegan, Shamian, & Wilk, 2001). Evidence has shown that empowered nurses shift their self-perceived role from that of a subordinate to collaborator; which encourages consensus building, improves job ownership, improves trust and the follower’s motivation, sense of responsibility and organizational commitment( Wagner ,2006 & Watson, 2002). Empowerment not only increases job motivation, but inspirational and visionary transformational leadership encourages the highest level of staff efficiency and productivity (Keuter, Byrne, Voell, & Larson, 2000; Moss & Rowles, 1997). Masi (2000) concluded that empowerment provides opportunities for choice and promotes autonomy, which allows subordinates to demonstrate their competencies.
The espoused benefits of empowerment
The supposed benefits of empowerment can be broadly divided into two areas: benefits for the organization; and benefits for the individual. Much of the empirical research into empowerment has focused on organizational benefits assuming that these are the driving force behind attempts to engender empowered working (Cunningham et al., 1996). Certainly the motivation for managerial adoption of empowerment is typically driven to help managers manage and improve work organization and job performance, not to primarily create an environment that is beneficial for the employee (Psoinos and Smithson, 2002). Global competition and a changing business environment have prompted organizational change in response to increased pressures to improve efficiency and performance (Lawler et al., 1992). It has been argued that organizations with higher levels of empowerment have demonstrated improvements in various economic performance areas (Applebaum et al., 1999). The economic benefits of empowerment specifically may be difficult to assess as often it is introduced as part of a broader initiative such as BPR and TQM (Psoinos and Smithson, 2002). Despite the espoused organisational benefits Argyris (1998) argues that empowerment has still not delivered the promised benefits, remaining a myth rather than reality. While it could be argued that the primary motive for empowerment is initially driven by the need to improve the economic performance of the organisation, benefits to the individual employee have also been identified. Nykodym et al. (1994) found that employees who consider themselves empowered have reduced conflict and ambiguity in their role, as they are able to control (to a certain extent) their own environment. They suggested that this reduces emotional strain on the employee. Similarly, it has been suggested that empowered employees have a greater sense of job satisfaction, motivation and organisational loyalty (Koberg et al., 1999, Spreitzer et al., 1997). Empowerment cannot only impact attitudes but it can also impact on performance, specifically employee productivity (Koberg et al., 1999) and employee effectiveness (Spreitzer et al., 1997). Overall the literature points to many potential benefits to both organisations and employees like if the workplace empowerment is successful, then it produces a “win-win” situation (Lashley, 1999). However, despite the strong support for empowerment in theory, in practice empowerment may exist in rhetoric only and control is the reality for employees (Sewell and Wilkinson, 1992). Although it may be considered that employee empowerment will improve organizational performance but it is possible that empowered employees are not necessarily more motivated or have higher levels of job satisfaction (Collins, 1999). Thus the benefits of empowerment should not be assumed to automatically occur nor should the rhetoric of empowerment be confused with the reality. Measurement of the employee benefits is very difficult to achieve. Unlike organisational benefits which can be measured using objective “facts”, individual benefits are much more complex. Certain objective measures, such as absence and turnover rates have been applied in this context (Psoinos and Smithson, 2002). However, it is often considered that softer measures of employees’ attitudes may provide informative insights omitted by other more tangible measures (Psoinos and Smithson, 2002).
FACTORS IMPORTANT FOR MOTIVATING EMPLOYEES
One of the most perplexing healthcare retention issues is keeping newly licensed nurses from leaving after just a year or two of employment in the clinical setting (Zucker, Goss, Williams, Bloodworth, Lynn, Denker, et al., 2006). Kovner, Brewer, and Djukic (2007) presented evidence that 13% of newly licensed 1490 RNs had changed principal jobs after one year, and 37% reported that they felt ready to change jobs. Nurses leave the profession mainly because of low pay and poor job satisfaction (DiMeglio, Padula, & Piatek, 2005)Hence pay and motivation at workplace are very important factors of retaining the staff. Therefore, nurse leaders are faced with two challenges: to recruit sufficiently qualified nurses and to establish rewarding work cultures that promote retention. Recruiting a younger generation of nursing staff members and meeting retention demands of cross-generational nurses will be a challenge like no other previously seen in healthcare (Cordinez, 2002). Newly licensed nurses’ recruitment and retention into the workplace are fundamental strategies for ensuring that healthcare systems have the continued capacity to deliver patient care (Berliner & Ginzberg, 2002). Understanding why newly licensed registered nurses choose to remain in nursing is an essential component of recruitment and retention strategies. Despite a recent four year trend of increasing nursing school enrollment and graduation of qualified nurses (American Association of Colleges of Nursing, 2005), the latest data on the shortage of RNs in the United States is estimated to reach about 500,000 by 2025 (Buerhas, Staiger, & Auerbach, 2000.This study shows that nursing shortage is going to increase and hence motivating factors like pay,proper work environment and empowerment are necessary for retaining the experienced nurse staff. Hecker (2005) predicts that more than one million new and replacement nurses will be needed by the year 2014. The problem is that many of the newly licensed nurses will not remain in nursing and will choose to leave the profession within four years of graduation from a nursing program (Sochalski, 2002). In a study by Bowles and Candela (2005), 30% of newly licensed RNs left their first nursing position within one year of employment, and 57% left their first nursing position within two years of employment.This study further provides evidence that adds to the case study done by Kovner, Brewer, and Djukic (2007) which also adds to data and evidence that nurses are leaving their profession due to lack of empowerment and motivation in hospitals.
The nursing shortage and the high incidence of turnover among newly licensed nurses within the first year of employment need to be investigated. It is well documented that nurses are leaving the profession because they are dissatisfied with current working conditions and not because they are disenchanted with the ideal of nursing, which originally attracted them to the profession (Lynn & Redman, 2005; Strachota, Normandin, O’Brien, Clary, & Krukow, 2003). There is limited research that addresses newly licensed registered nurses’ career choices post-graduation. The future of nursing rests in the ability to recruit and retain upcoming generations to the profession.Currently, however, there is limited knowledge concerning what influences the decisions of newly licensed registered nurses to remain in nursing. Thus, the objective of this study was to identify factors that influence newly licensed registered nurses’ decision to remain
in nursing. The shortage of people entering professional nursing, nurses’ dissatisfaction, and high turnover of newly licensed registered nurses are issues of concern. The national shortage in the nursing workforce highlights the critical importance of encouraging nurses to remain in practice. Evidence suggests that a shortage of nurses is detrimental not only to quality of patient care, but also to staff morale, which in turn affects staff retention (Wilson, 2006). The socialization and assimilation of newly licensed nurses into the healthcare system is a pivotal event that influences the retention of nurses (Aiken, Clarke, Sloane, Sochalaski, & Silber, 2002). Professional socialization and work readiness are contributing factors to the retention of newly licensed registered nurses. The transition from student to new nurse is a vital period in several ways. It is the quality of this transitional experience that is likely to influence new nurse retention (Clare & van Loon, 2003; Duchscher, 2001; Ewens, 2003). Professional socialization, a potential buffer to the effects of reality shock, includes the acquisition of knowledge, skills, identity, occupational traits, values, norms, and self-concept (Mamchur & Myrick, 2003). The process of professional socialization, from career choice to transition to enculturation to the practice setting is influenced by others, especially other nurses (Beck, 2000; Hinds & Harley, 2001). It is this initial professional socialization of nurses that will determine the success or failure of retaining new nurses in the healthcare workplace. The increasing complexity of health services and the acuity of patient care create an expectation by the healthcare organization that the new nurse will “hit the ground running” (Cowin & Hengstberger-Sims, 2006, p. 61). Furthermore, Cowin and Hengstberger-Sims believe the workplace expects newly licensed nurses to quickly fulfill their potential as knowledgeable workers, but the health organization remunerates newly licensed nurses at the lowest possible pay scale. These researchers asserted that incongruencies such as high level of stress related to responsibility and high workloads paired with minimum pay compound the effects of reality shock of nurses new to the field.
The healthcare workplace demands work readiness from its newest nurses and the partnership of responsibilit
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