Why is Motivation Important in Health Care?

What is a motivated health worker?

Human resources are vital to an effective health care system ^[1]. From an economics viewpoint, health workers’ salaries make up a great share of health budgets in most countries ^[1]. The health worker is the gatekeeper of the health system.

In the workplace, motivation can be defined as an “individual's degree of willingness to exert and maintain an effort towards organizational goals”^[2]. Motivation is closely linked to job satisfaction, which retains workers at their jobs over time ^[3]. Health worker retention reduces costs to the health system of having to recruit, hire, and orient new workers and also reduces the likelihood of vacant posts ^[4]. As many countries currently experience a shortage of qualified health workers ^[5], the loss of any health worker—especially doctors and nurses—has serious ramifications for the health of people in that country ^[6]. Keeping health workers satisfied and motivated helps the entire health system work smoothly ^[2].

Poorly motivated health workers can have a negative impact on individual facilities and an entire health system ^[7]. Unmotivated health workers greatly impact rural areas. Often it’s these health workers who work longer hours, whose workplaces have fewer resources than urban health centers, and where they can feel most isolated ^[8]. Unmotivated health workers are known to leave their jobs, either leaving rural and remote areas for work in larger cities, or migrating to other countries in the pursuit of more appealing job opportunities ^[7]. Some disgruntled health workers have been known to leave the medical field outright ^[9].

What motivates health workers?

Motivation is influenced by a complex set of social, professional and economic factors ^[10]. There are many reasons health workers remain motivated and decide to stay at their jobs. Generally, a health worker will be motivated and express job satisfaction if they feel that they are effective at their jobs and performing well. Factors contributing to motivation and job satisfaction also include strong career development, an adequate compensation, and adequate working and living conditions ^[10]. Having strong human resources mechanisms in place within a health system can help to ensure that the right motivational factors are in place at adequate levels to keep health workers satisfied.

Maintaining a positive relationship with coworkers can increase motivation. In a study in Ethiopia, nurses experienced more job satisfaction if they felt they had greater autonomy to make their own decisions regards to patient needs ^[9].

However, inversely, problems with career development, salary and working/living conditions are also reasons health workers become unmotivated. Any of these issues—or a combination of them—can lead to health worker dissatisfaction.
Career development is generally defined as the possibility to specialize in a specific field or be promoted through the ranks of health workers ^[12]. Doctors and health workers laboring in rural settings commonly cite limited career development opportunities as a demotivating factor ^[13]. A study of South African doctors working in rural areas found that many complained about being unable to connect to online training courses to learn a specialty ^[13]. A lack of promotion opportunities is another problem. Nurses in Tanzania reported working for as many as ten years without a promotion ^[14]. This has led to bad feelings, where the researchers point out that simple communication—such as staff appraisals and transparent promotion procedures—could lead to better morale ^[14].

Having limited continuing professional development opportunities—or proper training during preservice education or on the job—is another major theme among discontented health workers ^[12]. In understaffed clinics and hospitals in Tanzania, health workers are often asked to perform tasks beyond their scope of practice, but without adequate training. This can lead to frustration and demotivation ^[14]. This also creates concerns about the quality of health services provided.

Inadequate and outdated medical resources and supplies at clinics and hospitals can also contribute to health workers’ frustration on the job, and eventual attrition. Health workers argue that a dearth of adequate resources prohibits them from doing their jobs ^[12]. Doctors in South Africa reported they left their employment at rural clinics due to a lack of appropriate facilities, materials, and medical equipment ^[13].

Another issue is maintaining a positive relationship with management ^[12]. In some cases, vacant positions are left unfilled for long periods of time, increasing workloads for remaining health workers ^[13]. Health workers, often in rural areas, complain of a lack of supervision (or irregular supervision) from their managers or supervisors ^[14]. Staff feedback is especially problematic. Health workers complained to Manongi et al. ^[14] that the only feedback they received from supervisors was negative in nature.

Complaints about salaries is another issue. Health workers in Uganda complained to researchers that they do not earn enough salary compared to other civil servants of equitable professions ^[15]. In Bangladesh, health workers complained that they aren’t paid on time by the government, which is sometimes six months behind in salary dispersal ^[15].

How to strengthen health worker motivation?

Motivation strategies should approach these complex problems holistically: provide opportunities for career development, make efforts to ensure adequate compensations, and promote positive work environments, including supportive supervision ^[3],[16].
Knowing that there is room within a health worker’s career for further development is a critical factor in motivating health workers and allowing them to continue to meet the changing medical needs of their communities ^[17]. Increasing the number of job opportunities, whether is moving up the organization hierarchy or provided with the ability to learn new things, is an important indicator of job satisfaction ^[17]. Career planning – whether personal or institutional – allows health workers to increase learning and job commitment. Organizations or health systems which assist health workers in planning their careers can improve morale and encourage retention of ambitious personnel ^[18].

In low-resource countries, increasing salaries may not be realistic ^[19]. Tino Maliselo and Rita Magawa ^[19] argue that a more cost-effective method to augment motivation for health workers in rural areas would be for governments to provide more amenities and infrastructure (such as better roads) in those areas. A study in Asia and the Pacific found health workers value modern working facilities with proper water and sanitation systems and up-to-date lighting and communication technologies ^[8].

This method can also work for health workers in other locations. Providing safer and more pleasant working conditions increase health care workers’ productivity and quality of service ^[4]. In Kenya, health facilities successfully increased staff motivation and pride by undertaking such low-cost interventions as cleaning the public areas of health facilities, growing flowers onsite and offering free tea to staff in break rooms ^[20].

Insuring health workers feel safe at their job is also important to motivation, productivity and their decision to remain at work ^[10]. This includes such issues as providing health workers access to clean water; insuring workers have adequate supplies of safety equipment and are trained to handle chemicals properly; further, making minor adjustments to the physical environment – such as increasing ergonomics of equipment and decreasing the amount of heavy lifting for health workers – decreases the amount of absenteeism ^[10].
Following positive management protocols and providing quality supervision is also important ^[21]. This can be done by improving the overall quality of managing. Examples include employing properly-trained managers who set clear expectations ^[11]; ^[3] increasing the time they spend with health workers ^[8]; having them provide appropriate and constructive feedback ^[22]. and establishing transparent incentive schemes ^[3].

Deussom and Jaskiewicz ^[4] argue that well designed performance-based financing systems or other types of payments for performance plans can reinforce accountability for particular services through verification and more or better supervision. Increasing accountability will compel staff to have a greater stake in meeting the facility’s performance goals ^[4].

But challenges often exist. Supervisors often lack quality management tools. Supervisors can have a hard time acquiring proper transportation to make trips to visit health workers. Managers also spend a lot of time fulfilling administrative duties for donors and their own administration ^[21].

Motivating health workers does not fall only on their supervisors. Health workers from rural backgrounds or with rural work experience are more likely to be motivated to go and work there ^[23]. National policy-makers and stakeholders have roles to play, too. Developing national plans to attract, motivate, and retain health workers should be conducted through evidence-based decision-making ^[4]. This includes leveraging proper data to help drive policy and decisions ^[4]. However, when working with health systems, it is often difficult to know what to measure – especially in the developing world ^[3].

Any motivation and retention strategy is not complete without a cost-benefit analysis, which allows policy-makers to weigh the pros and cons of specific proposals ^[24]. Policymakers should gather a diverse mix of stakeholders to ensure proposed policy changes are properly vetted. Finally, careful communication is necessary to ensure proper expectations are set for the health workers ^[24].

References

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2. Franco, Lynne Miller, Sara Bennett, and Ruth Kanfer. "Health sector reform and public sector health worker motivation: a conceptual framework." Social science & medicine 54, no. 8 (2002): 1255-1266.
3. Luoma, Marc. "Increasing the Motivation of Health-care Workers." Capacity Project Technical Brief 7 (2006).
4. Deussom, Rachel, Jaskiewicz, Wanda “Using Evidence for Human Resources for Health Decision-Making: An Example from Uganda on Health Workforce Recruitment and Retention.” (2014)
5. World Health Organization. "The world health report: 2006: working together for health." (2006).
6. Eastwood, John B., Rachel E. Conroy, Sarala Naicker, Peter A. West, Roger C. Tutt, and Jacob Plange-Rhule. "Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK." The Lancet 365, no. 9474 (2005): 1893-1900.
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18. American Society of Health-System Pharmacists. "ASHP guidelines on the recruitment, selection, and retention of pharmacy personnel." Am J Health-Syst Pharm 60 (2003): 587-93.
19. Maliselo, Tino, and Rita, Magawa. 2013. Retaining doctors in rural Zambia: A policy issue.
20. The Capacity Project. 2009. “What about the health workers?” Improving the work climate at rural facilities in Kenya. Voices from the Capacity Project, no. 27. Chapel Hill, NC: The Capacity Project.
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24. Ditlopo, Prudence, Duane Blaauw, Laetitia C. Rispel, Steve Thomas, and Posy Bidwell. "Policy implementation and financial incentives for nurses in South Africa: a case study on the occupation-specific dispensation." Global health action 6 (2013).