CHAPTER 3. Motivating People. Myron D. Fottler, Stephen J. O Connor, Mattia J. Gilmartin, and Thomas A. D Aunno

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1 sho01910_ch03 10/21/05 12:46 PM Page 21 CHAPTER 3 Motivating People Myron D. Fottler, Stephen J. O Connor, Mattia J. Gilmartin, and Thomas A. D Aunno LECTURE OUTLINE A. Chapter Purpose The objective of this chapter is to explain how to motivate individuals to perform effectively in health services organizations. B. Motivation and Management 1. Defining and Distinguishing Motivation Motivation is a state of feeling or thinking in which one is energized or aroused to perform a task or engage in a particular behavior. This definition focuses on motivation as an emotional or cognitive state that is independent of action, and clearly distinguishes motivation from the performance of a task and its consequences. 2. Myths about Motivation and Some Antidotes a. Motivated workers are more productive. b. Some people are motivated and others are not. c. Motivation can be mass produced. d. Money makes the world go round. 3. Manager s Role Managers can play a critical role by not only assessing their employees motivation but by taking the lead to alter conditions that can increase motivation. C. Content Perspectives Content theories focus on needs and need deficiencies. Unmet needs create a state of disequilibrium within a person which, in turn, creates a desire to meet the need or needs he or she is experiencing. 1. The Need Hierarchy Maslow s (1943) hierarchy of needs assumes there are five need levels that must be satisfied sequentially: physiological, security, belongingness, esteem, and self-actualization. People are motivated first to satisfy the lower-level needs; as long as these remain unsatisfied, the individual is motivated only to fulfill them. 2. ERG Theory As a result of criticisms of Maslow s theory, Alderfer (1972) proposed an alternative hierarchy consisting of three levels: existence, relatedness, and growth. The theory suggests that more than one level of need can motivate behavior at the same time. 21

2 sho01910_ch03 10/21/05 12:46 PM Page SECTION ONE Chapter Outlines and Support Materials 3. Two-Factor Theory Herzberg et al. (1959) distinguished between two factors: motivators and hygiene factors. Motivators are intrinsic factors such as achievement, recognition, the work itself, responsibility, and advancement. Their presence increases job satisfaction and motivation, but their absence does not lead to dissatisfaction. Hygiene factors are related to the work environment and include supervision, salary, and working conditions. The presence of positive hygiene factors prevents dissatisfaction but does not lead to satisfaction and motivation. 4. Learned Need Theory McClelland (1961, 1975) identified three needs and related them to performance in organizations. These needs are achievement, power, and affiliation. All three needs are acquired; individuals develop these needs to varying degrees through life experiences; they are learned needs evolving from one s background and environment. 5. An Assessment of Content Theories Five caveats regarding the use of content theories are presented: a. People differ in terms of age, sex, race, and other demographic and background characteristics, so no one set of motivators is likely to be appropriate for all employees. b. The learned needs of a given individual may vary depending on the incentives present in his or her organization. c. For a given individual, needs change over time. d. Employees in different positions in an organizational hierarchy will differ in terms of needs and potential motivators. e. Resource constraints or lack of such constraints may impact the relative importance of various needs. D. Process Perspectives These approaches attend to the context in which work is done as well as an individual s reactions especially thoughts and feelings to work. 1. Equity Theory Adams (1963, 1965) proposed a theory of work motivation that assumes that individuals value and seek fairness, or equity, in their relationships with employers. Relationships are fair when people perceive that their outcomes (e.g., pay) are proportionate to their perceived contributions or inputs (e.g., task performance). Further, people evaluate fairness by comparing themselves to others. 2. Expectancy Theory Vroom s (1964) theory assumes that people are rational decision makers who will expend effort on work that will lead to desired rewards. The theory assumes that people know what rewards they want from work and understand that their performance will determine the extent to which they attain the rewards they value.the three components of the model are: job outcomes (both rewards and negative experiences), valences (individuals feelings about job outcomes), and instrumentality (the perceived link between performance and outcomes). 3. Reinforcement Theory Also known as operant conditioning or behavior modification, reinforcement theory (based on the work of B. F. Skinner) has three components: stimulus, response, and consequence. There are three types of consequences: positive reinforcement, punishments, and negative reinforcement.

3 sho01910_ch03 10/21/05 12:46 PM Page 23 CHAPTER 3 Motivating People Goal Setting Locke (1968) proposed a motivation theory that focuses on the role of goals and goal setting. Goals direct people s attention, focus effort on tasks related to goal attainment, and encourage people to persist. The more difficult and specific the goal, the greater will be the motivation to attain it; a goal provides guidelines for how much effort to put into work. 5. Motivating Health Care Professionals and Support Personnel Health care organizations have large numbers of autonomous professionals working for them. Caution is required in applying motivational theories to professionals. Herzberg s motivation-hygiene theory is one example of a motivational theory that needs some adaptation in applying the concepts to professionals. According to Herzberg s theory, money acts as a hygiene factor. If financial rewards are perceived as inadequate, then dissatisfaction may occur; however, ample rewards do not result in satisfaction or motivation. Health care professionals often have high achievement needs, and therefore money might serve as a motivator to the extent it is viewed as a tangible recognition of ability and achievement. Managers may especially find it difficult to motivate physicians due the high degree of autonomy that is normally associated with their profession. Feedback can be a powerful tool to assist managers in motivating physician behavior.there are several factors that maximize feedback effectiveness: a. Physicians must truly see that their behavior needs to change. b. Feedback needs to be frequent, timely, and given at precise time intervals to sustain new behaviors. c. Feedback must be usable, consistent, correct, and of sufficient diversity. d. Managers should not portray the feedback as good or bad. Not all clerical and service employees respond to the same incentives as physicians and may not exhibit as many higher-order needs as physicians. For example, a manager who assumed such needs among all staff members might be surprised to learn that some support personnel will not respond to opportunities for autonomy and personal growth on the job. Rather, they may view their jobs as means of providing income and seek various forms of personal fulfillment off the job through their families and leisure activities. Health care managers need to determine what will motivate various support personnel, not assume that what motivates the manager and professional colleagues will motivate all others. 6. An Assessment of Process Theories Each process theory has limitations that make it incomplete for understanding and motivating behavior. Taken together, process theories offer a powerful set of guidelines for managers, and suggest a cycle of managerial action as follows: a. Goals should be set at the time of hiring or at periodic performance evaluations. b. Expectations about goal attainment and consequences should also be set at this time. c. Perceptions of fairness should be checked periodically. d. Reinforcement should be given contingent on performance. E. Motivational Problems 1. Nature and Causes Symptoms of motivation problems include apathy, low-quality work, and complaints from supervisors and patients. Causes fall into three categories: a. Inadequate performance definition (employees do not fully understand what is expected of them). b. Impediments to performance (obstacles, inadequate resources, mismatch between employee s skills and job requirements).

4 sho01910_ch03 10/21/05 12:46 PM Page SECTION ONE Chapter Outlines and Support Materials c. Inadequate performance-reward linkages (inappropriate or inadequate rewards, poor timing of rewards, inequity in distribution of rewards). 2. Potential Solutions Table 3.2 outlines potential solutions to the three motivational problems discussed in the preceding section. 3. Overall Assessment Whether a particular approach succeeds in a given setting depends on whether it was properly matched with the causes of low motivation, how the program was introduced and implemented to minimize resistance and maximize commitment, and whether the program is compatible with other aspects of the organization s culture. OVERVIEW OF CHAPTER IN PRACTICE AND DEBATE TIME MATERIAL Dr. Intimidation 1 Explain and distinguish factors and situations that influence individuals motivation and performance, in particular in the case of Dr. Intimidation. If the situational environment is poor (e.g., condescension, intimidation, verbal abuse, and disrespect), it is difficult for people to remain motivated.this demotivation can have a direct impact on patient care and safety. 2 Explain what roles managers and clinical leaders play to improve staff morale and motivation, in particular in the case of Dr. Intimidation. Because individuals motivation can vary over time and with the type and duration of work they are performing, it is incumbent upon managers and clinical leaders to periodically assess motivation and performance, taking into account occupational, career stage, and personal factors. Such assessments should include discussions with other employees and coworkers to understand the individual s needs, motives, perceptions, and values. Managers and clinical leaders must also establish and maintain the environment that will reinforce and facilitate the employees motivation. As in the Dr. Intimidation case, if the situational environment is poor (such as typified by condescension, intimidation, verbal abuse, and disrespect), it is difficult for individuals to remain motivated and institutions to meet their goals of high quality and maximum patient safety. A Cry for Help 1 In this case what work-related factors are demotivating the nursing staff? Nurses feel they are not getting the appreciation and respect for the amount of work they do in providing patient care. Demotivating factors include the shortage of nurses and downsizing of trained support personnel, which have resulted in extended work shifts, mandatory overtime, and a lack of adequate staffing to meet patient care needs. 2 What role do managers and clinical leaders play to improve staff morale and motivation in this situation? Managers should take an active role in systematically assessing the motivation of their employees and coworkers, taking into account the occupational, career stage, and personal factors of those involved. Such assessments should include informal interviews with employees and coworkers in which open-ended questions are asked about individuals needs, motives, perceptions, and values.

5 sho01910_ch03 10/21/05 12:46 PM Page 25 CHAPTER 3 Motivating People 25 Motivating a Primary Care Physician in an HMO 1 What is the basic motivational problem illustrated through this case? The motivational factors relevant to this case are: the degree to which individuals value the desired outcome, their belief that performance will be rewarded with desired outcomes, and their belief that their efforts will produce good performance. Some disease management guidelines require expensive short-term costs for effectively managing patients, limiting the bonuses certain primary care physicians are eligible for at year s end. This arrangement can cause a temporal delay or a break in the linkage between the performance and feedback regarding their performance (efforts can produce good performance), and between the desired performance and the reward (performance can produce desired outcomes and reward). 2 Instead of a holdback bonus, what other performance-enhancing incentives could the management team at this HMO use to change physician practice patterns? Organizations can link outcomes and rewards to performance, or improve the linkage between outcomes and performance by placing greater emphasis on quality indicators as a condition of participating in the bonus incentive pool. The M.D. Factor 1 Consider the following concepts as they pertain to The M.D. Factor: Motivating Health Care Professionals and Support Personnel. See Table 3.2, Common Employee Motivation Problems and Potential Solutions. Staff Motivation at Sharp HealthCare 1 Identify key characteristics of the content of peoples work that motivates them in relation to Staff Motivation at Sharp HealthCare. The simultaneous introduction of several mutually supportive and mutually reinforcing motivation programs, such as financial incentives, goal setting, and open communication between management and employees, was probably the most effective in overcoming motivation problems. 2 If you wanted to implement a program in your organization, what elements would you include in your implementation plan? What metrics would you use to measure the success of the initiative? There are many ways to approach this question depending on the organization, the current challenges it faces, individual organizational goals, and timing amidst those goals. Sharpe approached their program by focusing on five essential behaviors and actions to promote an atmosphere of friendliness, gratitude, stewardship, and service, all of which follow characteristic pathways to improving institutional morale and motivation. Sharpe defined and implemented specific, explicit, actionable steps that employees would follow to develop this friendly, open atmosphere. Other institutions may take similar steps, but prioritize differently. For example, an organization in which taking people where they are going, rather than pointing or giving directions was already the norm might choose to prioritize and capitalize on this strength, or it might choose to focus on other specific institutional deficits where it felt it needed to improve.

6 sho01910_ch03 10/21/05 12:46 PM Page SECTION ONE Chapter Outlines and Support Materials DISCUSSION QUESTIONS AND SUGGESTED SOLUTIONS 1. How can content and process motivation theories best be combined in practice? Each of the motivation theories presented in the chapter has some flaws and weaknesses. By using multiple theories, the weaknesses of one theory can be counteracted by the strengths of another. Content theories are useful in describing various levels of needs and need deficiencies; however, several caveats are mentioned in the text (e.g., needs differ between individuals within the same organization, and for a given individual, needs change over time). The process theories help us understand the individual thought processes that impact motivation, but do not recognize an individual s motivation to fulfill unmet needs. Taken together, the two types of theories can help managers gain a better understanding of the motivational problems in their workforce and develop effective interventions. 2. How can managers distinguish a motivational problem from other factors that affect an individual s performance? Managers can take steps to eliminate organizational impediments to performance. These include ensuring that necessary resources are allocated and giving sufficient support to employees. Managers should also focus on better matching of employee and job through improved selection and job design. If organizational impediments to performance are removed, then the employee has sufficient resources and the ability (knowledge, skills, etc.) to perform the job. Poor performance then will likely be a motivational problem. 3. How can motivational theories be used to select the best potential solution for a given individual s needs? A variety of communication methods should be used to assist managers in determining the nature and causes of employee motivation problems, including direct supervisor communication, interviews, and employee attitude surveys. It is then important to develop interventions that are properly matched with the causes of low motivation. For example, if it is determined that a primary cause of low motivation is an inadequate performance definition, then one potential solution would be to develop welldefined performance standards. The various motivation theories are useful in that they help managers understand the nature of the problem and select the most appropriate and effective interventions. TEACHING TIPS AND EXERCISES 1. Consider using the following assignment to reinforce the relationship among the various content perspectives. Give students a list of various management practices, and ask them to indicate which of Maslow s, Alderfer s, and Herzberg s motivational categories correspond to each management practice. Some examples of management practices that might be used in this exercise are: implementing employment contracts, giving employees more decision-making autonomy regarding job assignments and hours, holding company picnics or other outings, and forming cross-functional work teams. This exercise will give students the opportunity to think about the motivational implications of specific management practices. 2. A self-assessment exercise can be useful in helping students better understand the implications of McClelland s learned need theory. This could be accomplished in several ways. Students could be asked to write an essay indicating which of these categories of needs is the most motivating to them (or, in lieu of a writing assignment, this could be a class discussion topic). An alternative would be for students to complete a self-assessment exercise that is then scored, giving students a quantitative measure of their needs for achievement, power, and affiliation. These self-assessment exercises are available from a variety of human resource textbooks. Whichever approach you use, ask students to identify some of the implications of their own needs. What steps could their managers take to create jobs that are motivating to them, based on this knowledge? 3. In the discussion of content perspectives, it might be helpful to spend some time discussing extrinsic

7 sho01910_ch03 10/21/05 12:46 PM Page 27 CHAPTER 3 Motivating People 27 versus intrinsic motivating factors, relating these to the various content theories. Maslow s and Alderfer s theories, in particular, can be described as a continuum in which individuals are motivated by extrinsic needs at the lower levels, with the needs becoming increasingly intrinsic at the higher levels. Herzberg s and McClelland s theories can also be defined in terms of extrinsic and intrinsic needs, although they do not follow a similar continuum (which may be more in keeping with the way students describe their own motivation, i.e., that several motivating factors some extrinsic and some intrinsic may be operating simultaneously). COMPLEMENTARY READINGS Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288(16): Aiken, L. H. (2001). Evidence-based management: Key to hospital workforce stability. Journal of Health Administration Education, Spec No: Lowenstein, R. (2005). The quality cure? New York Times Magazine, March 13, Rafferty, A. M., Ball, J., & Aiken, L. H. (2001). Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Quality Health Care, 10(Suppl 2), Thomas, K. W. (2002). Intrinsic motivation at work: Building energy & commitment. San Francisco: Berret- Koehler. Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P.,& Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42(2 Suppl), II57-66.