Health workers' motivation: strong professional ethos mixed with frustration
Health workers' understanding of motivation
As mentioned above, motivation can be defined as the willingness to exert and maintain an effort towards attaining organizational goals. Yet, when health workers are asked about their definition of motivation ("What does being motivated mean to you?"), a different understanding emerges.
As Table shows, over 50% of health workers in Benin equate motivation with prospective "encouragement" or retrospective "re-compensation", which is understood as making them work better. Out of these, one fourth explicitly mention financial encouragement. Another 40% consider "being motivated" as having the means and material to work, to get recognition, or other HRM tools, such as awards, supervision and good leadership. Hence, the majority understands motivation as a "motivator", i.e. an incentive, and not as a state of mind. Only 5% refer to motivation as the "willingness" or the "pleasure" to do one's work, similar to the above definition, from the literature, of motivation as an intrinsic process and state of mind. Not surprisingly, the latter group are mainly doctors and health workers in the private sector.
Health workers' understanding of motivation
In Kenya, one fifth understand motivation as encouragement. However, there is a larger share of health workers who refer to that intrinsic state of willingness and pleasure to do one's work. This difference in the connotation between Kenyan and Benin respondents may be due to the fact that so-called "motivation allowances" ("primes de motivation") have been introduced in Benin, that may have changed the meaning of motivation from a state of mind to that of an incentive.
This understanding of motivation matches health workers' perceptions of motivational consequences: For the majority of Benin respondents (70%), motivating someone serves to improve work performance, while only 30% perceive motivation as a means to increase job satisfaction and job attachment. Again, for Kenyans, there is a stronger focus on the satisfaction element (48%). Especially in Benin, this view of motivational consequences may represent a legacy from previous decades, when job satisfaction and pleasure were not part of the prevailing organizational cultures. As one key informant put it, individual health workers were merely seen as a part of the production chain.
The introduction of a quality management system, which is currently under way in Kenya and partly in Benin, may provide the opportunity to gradually change this mindset and to give the word motivation a new meaning. Alternatively, it may seem necessary to avoid the word motivation altogether and use a different terminology, such as for example "boosting one's work spirit or work morale".
In contrast to their own definition of motivation, health workers were asked to assess their level of motivation, by considering the following definition: "Willingness to do a good job, according to organizational objectives" (see Figure ).
Self-assessment of motivation level.
The health workers' replies suggest that they may not have responded in line with the given definition, but also referred to their own understanding of motivation. With the caveat that the validity of the answers may be somewhat limited, more so as the Likert scales for Benin and Kenya were not internally validated, the figure still provides an overall idea of how health workers see their own level of motivation: In both countries, more than 55% do not place themselves in the categories "rather good", "high" or "very high".
In Benin, health workers from the private sector/NGO facilities appear more motivated than those in public health facilities. Two thirds assess their level of motivation as "very high", "high" or "rather good" (14/21), compared to around a quarter from the public services (11/41). Nurses from the public sector appear to be the least motivated group and therefore a likely focus for efforts to increase motivation by means of human resources management and incentives. In Kenya, such clear tendencies cannot be derived, but then the sample size is also much smaller.
Motivational determinants: professional values and goals versus endangered self-efficacy
To identify the motivational determinants that account for perceived level of health worker motivation, respondents were asked: "Which aspects currently encourage you to undertake efforts to do your work well?" (Figure ). As Benin respondents gave longer answers, mentioning several aspects, percentage figures in Figure are higher for Benin.
Aspects that encourage to do one's work well, in %, in Benin (N = 62), Kenya (N = 37).
Health workers in Benin strongly referred to vocation and professional conscience, i.e. their personal professional values. Likewise, the wish to help patients and professional satisfaction were frequently mentioned. Pangu [21
] carried out a study in Benin on the reasons why health workers stay in function despite decreasing motivation and identifies exactly those four aspects. Among Kenyan respondents, vocation was equally very dominant. Also, healing patients, professional satisfaction and recognition were considered important. These aspects nurture health workers' goals. Both dimensions – values and goals – indicate a strong professional ethos and commitment and strongly appear to translate into the "will-do" component of the motivation process.
Other factors, such as work environment and HRM tools that relate more to the "can-do" component are also mentioned, but particularly in Benin they do not feature as prominently as values and goals. About 6% of respondents in Benin and Kenya mention regular salaries and allowances. Finally, half of the health workers in the private sector in Benin, that is 10% overall, consider that earning revenue is an important encouragement to do one's work well.
When health workers were asked, with respect to the future, what would have to happen so as to boost their spirit and increase their willingness to perform (this was asked only of Benin respondents, see Figure ), they emphasize to be able to perform one's work, namely having the materials and means available as well as further training and supervision. This corresponds with the findings of Alihonou et al. [12
], as well as with a staff survey from Zimbabwe cited in USAID [22
], which revealed that the number one reason provided by health workers for resigning their government job was the lack of equipment and supplies.
Benin: "How to boost your spirit and willingness to perform" (in %, multiple responses, N = 62).
Also, a more conducive working environment and atmosphere, recognition and feedback, and other HRM tools such as better leadership, management and participation, are reported to contribute to increasing health workers' self-efficacy, i.e. their self-perception of being able to do a good job and fulfil their duties ("can-do" component of motivation). It also emerged from the interviews that health workers appreciate small benefits as relevant to their motivation. For example, in public health facilities, unpaid holidays or small amenities such as free tea for staff on night duty were perceived as motivating. Their absence, temporary or permanent, was considered demotivating.
The two questions on current versus future motivational determinants accordingly revealed different answers: Several aspects that featured low under the question on current motivational factors – precisely due to their (perceived) non-existence or poor state, such as organizational factors – then emerged in the second question as potential motivating factors.
Table and Figures and also reveal that health workers self-evidently desire better salaries and living conditions, including better communication facilities. These aspects do not dominate, however. Instead, very prominent were health workers' request and need for available means and materials to carry out their work in a professional way. Subsequent questions, e.g. how health workers could improve their performance, persistently revealed the frustrations that health workers experience because of the lack of means and materials and the inadequate work environments as well as deficits in HRM.
It appears that these frustrations are so strong precisely because of the high professional commitment of health workers. In fact, there is a danger that perceived self-efficacy, constrained by inadequate HRM and work environment, becomes so weak that it may ultimately negatively affect health workers' commitment and professional ethos.
Health workers' commitment and professional ethos is, moreover, endangered by the existence of HIV/AIDS, which, as for example Aitken and Kemp [23
] have shown for Southern Africa, has a severe impact on health workers' behaviour and above all attitude to work. In fact, throughout the interviews, health workers refer to HIV/AIDS issues. Asked about their feelings and reactions with respect to HIV/AIDS at the workplace, few health workers feel sufficiently protected. Most health workers fear becoming infected and report reacting in general more reserved towards patients. Some respondents said that every patient is seen as a potential source.
The next section assesses some core HRM tools and derives their effect on the "will-do" and "can-do" component of motivation. Respondents were asked about their experience with and perceptions of certain non-financial incentives and HRM tools. The findings reveal present shortcomings, but also reveal further potentials in the application of such tools, which is supported by the vast evidence and examples collected by the WHR 2006 [2
HRM tools: current pitfalls and further potentials
Supervision as control versus support supervision and recognition
Ideally, supervision is a formalized HRM instrument to correct shortcomings and to support good practice, on the basis of which recommendations are provided to help improve individual and facility performance. Supervision can contribute considerably to health workers' self-efficacy and relates therefore to the "can-do" component of Kanfer's model of motivation. To the extent that supervision is used to communicate a facility's goals and that it takes account of health workers' personal goals and needs, it also strengthens goal coherence and affects the "will-do" component of motivation.
The interviews revealed that 40% of respondents from Benin and more than 50% from Kenya perceive supervision as an exercise of control. As the following quotes reveal, existing schemes for supervision are sometimes perceived as unhelpful and distant, rather than personal and supportive:
"Supervision is not very useful. The supervisors remind nurses of the procedures they should apply. Right now, under given circumstances, you cannot implement them. They remind you of the rules and control you." (female nurse, 32 years, government facility, Kenya)
"While individual efforts go unnoticed, mistakes or shortcomings are noticed immediately." (female nurse, government facility, Kenya, in focus group discussion)
"The supervision went without difficulties, but the supervisors did not give me any feedback afterwards." (male nurse, 33 years, private facility, Benin)
Health workers criticize the low frequency and irregularity of supervision as well as the top-down approach used by supervisors. Supervision that involves discussions of health workers' conduct in the presence of patients is seen as particularly demotivating. Responses revealed that not knowing whether or when the next supervision takes place can also have a negative effect on health workers' commitment to improve their work.
In Kenya, almost half the respondents and one in ten of the respondents in Benin claimed that they do not receive any personal feedback from their superior. Judging from the answers provided, the feedback that health workers receive from their supervisors in rural facilities usually centres on specific shortcomings or technical aspects of service provision. It rarely appears to focus on the personal perspective of the health worker herself or himself. Feeling neglected by the superiors or the health administration has a strongly demotivating effect. There are indications that supportive supervision, recognition and personal feedback tend to be more common in religious and private health centres in Kenya than in public facilities.
Despite these shortcomings, health workers consider supervision useful and desirable to the extent that it helps improve personal performance, to avoid mistakes and to update knowledge. When personal needs and concerns are taken seriously, supervision provides the feeling of being cared for and of appreciation. This aspect appears particularly important for health workers posted to remote facilities with little contact with other professionals.
There is a large potential for improvement in the supervision process, according to the respondents' suggestions: Apart from a more frequent, regular and reliable supervision, many respondents ask for a different approach, in that supervision should be more supportive, instructive, needs-oriented, participatory and should provide a direct and timely feedback on their problems. There was also a call for more meetings to discuss problems and solutions. Direct observation of health worker activities is considered helpful to identify the bottlenecks in service delivery, provided that health workers are not criticized in front of the patients.
In conclusion, support supervision that exists appears to contribute significantly to health workers' self-efficacy. There are potentials to strengthen the "can-do" component of motivation through a more regular supervision routine and follow-up. Moreover, supportive supervision that takes account of the supervisee's personal and professional goals of recognition and learning and that communicates organizational goals clearly offers a potential for a positive motivational effect both in the "will-do" and "can-do" component that is so far not sufficiently used.
Lack of recognition versus institutionalized recognition and appreciation by superiors and communities
Through an encouraging and supportive attitude, superiors can strengthen their subordinates' self-efficacy and thus foster personal efforts for the achievement of organizational goals: the "can-do" component of motivation. Community recognition and appreciation can have the same effect.
While most felt that their leaders are accessible, critique focused on lack of encouragement and insufficient consideration of staff views, as health workers did not feel adequately supported and recognized by their superiors. In other words, the leaders seemed to fail to contribute as much as possible to strengthening health workers' self-efficacy. In general, health workers criticized their leaders' inadequate communication and bad treatment of staff. When leaders fail to be role models by not adhering to organizational goals, health workers may wonder why they should adopt them, thereby reducing the drive for the "will-do" component. In fact, a good number of respondents wished for supervisors to receive training on management and leadership issues. Clearly, health workers highly value recognition and appreciation from superiors and colleagues as well as patients. The role of good working relationships with superiors and colleagues similarly emerged as one important motivational determinant in a study in Georgia by Bennett et al. [7
However, asked whose appreciation health workers find most relevant, 80% of Benin and 50% of Kenya respondents referred to the patients' appreciation (see Figure ). There is no correlation by type of institutions, hence client appreciation is not of greater importance to health workers from the NGO and private sector than from the public sector. This is not to say that in practice, health workers are indifferent to their supervisors' appreciation. After all it is important for career promotion and adequate postings, but as Buchan [20
] also notes, the "avowed first loyalty [of doctors and nurses] tends to be to their profession and their patients ..."
Preferred source of appreciation.
Appreciation from clients is seen as an indicator for successful professional conduct and the achievement of the health workers' goal to cure patients. The importance of patient appreciation stems primarily from health workers' search for professional satisfaction and their professional goals of helping patients, as revealed throughout the interviews, for example:
"Appreciation from the patients is most important, because it is sincere and heartfelt." (male medical officer, 28 years, government facility, Kenya)
The above finding strongly supports ideas and efforts for strengthening community participation in health service provision. Client satisfaction surveys, community dialogue and interaction with health unit management committees should be managed in such a way as to not only ensure client orientation and accountability towards the community but also to convey appreciation and strengthen staff motivation. Such improved mechanisms may also help to reduce health workers' perceptions of too much interference by the community, lack of patient compliance or lack of cooperation by patients and their relatives. These issues formed frequent complaints by health workers and appeared to affect the "can-do" component of their motivation.
Inadequate training versus needs- and problem-adapted training
Training and professional progress are important motivational determinants, as they nurture health workers' personal objectives and their value system. In fact, training as a tool of human resources management can serve several purposes. It can help health workers to cope better with the requirements of their job. It can also enable them to take on more demanding duties and positions and to achieve personal goals of professional advancement. Training can have strong motivating effects.
When asked about the effect of training courses they had taken over the past two years, nearly all health workers in Kenya and Benin mentioned that they felt more comfortable and confident with their work afterwards. Some 20% also mentioned increased interest and work commitment. These answers suggest a considerable effect of training courses on both the "can-do" and the "will-do" component of motivation. Overall, respondents were very interested to receive more continued medical education/continued professional development. This is similar to other study findings [7
]. With respect to the contents required to fill gaps in their knowledge, they mentioned in particular training in management and administration as well as HIV/AIDS treatment.
The need to learn how to deal safely with HIV/AIDS patients through training in counselling and prevention was a recurrent theme among health workers. Basic training on HIV/AIDS prevention and care as well as having the means for care available appears to be a critical measure to help health workers maintain their morale and motivation, as indicated by such typical quotes as below:
"I have worked as a nurse before it [AIDS] came. Initially, I had a negative attitude to AIDS patients. There were many programmes. Now I am trained, so I have no more fear." (male nurse, 46 years, government facility, Kenya)
"Training changed me. It made me accept all patients and to share their feelings. I have no fear of patients anymore, I am more confident. I came back with new energy." (female nurse, 45 years, government facility, Benin)
Training may constitute a direct means to mobilize the motivational potentials inherent in the professional ethos of health workers. However, many respondents described the effect of training as short-lived or even frustrating:
"The training discouraged me because of the lack of equipment here. You cannot practise the information you were taught." (female nurse, 30 years, government facility, Kenya)
"The good feeling is gone in the government immediately. We don't have ultrasound. So the knowledge wears off." (male clinical officer, 30 years, government facility, Kenya)
Contents of courses and seminars that were out of touch with the reality of the rural health facilities of developing countries were considered the most important problem by health workers. After a training course, those confronted with treatment guidelines based on standards of equipment and supplies that do not exist at their workplace experience their daily work environment as an insurmountable obstacle to the provision of "adequate" health care. Improvisation to make up for shortcomings in equipment and supplies was considered inferior practice.
Overall, training can have a strong effect not only on the "can-do" component, but also on the "will-do" component of motivation. Yet, to have this effect, i.e. to exploit this motivational potential, training courses must be adapted to the local context: the actual working conditions in rural facilities.
Non-transparent allocation versus equal opportunities for training and professional progress
Further education and professional progress rank highest among the professional objectives of the nurses and doctors interviewed in Kenya and Benin. These objectives were mentioned by about two thirds of respondents. The answers reveal that the interest in further education is motivated by the chance to rise within the hierarchy of the health system, to reach a higher status and to increase earnings.
In Kenya, the prospect of sponsorship for further qualifications in the public health system appears to make public sector jobs more attractive for health workers working in private and mission facilities, although working conditions were acknowledged to be better in some of the private facilities.
Health workers in the public sector, by contrast, often feel demotivated by the limited realistic prospects of professional progress and personal advancement and the rather slow and cumbersome promotion process. Where access to training and further qualifications is limited or granted in line with reasons that are not equitably available or merit-based, this can likewise have detrimental consequences for the motivation effect of training as a tool of human resources management. The following quotes reveal that this results in dissatisfaction:
"It is necessary to make everybody participate in training opportunities, not always to privilege the same." (female nurse, 31 years, government facility, Benin)
"There is a problem with staff motivation. You work for four or five years in the same place. You find the same person goes to the same seminar in two years; why not rotate and train someone else the next year?" (nurse, government facility, Kenya, in focus group discussion)
Opportunities for training must be allocated in a transparent and fair way, since a sense of unequal treatment demotivates and leads to frustration. As such, it affects both the "will-do" and "can-do" component of motivation.
The use of training and further qualification as a human resources management tool is limited by financial resource constraints, of course. However, as individual examples show, there may be options for gradual improvement and needs-adapted training even in resource-poor rural settings. In Kenya, whereas the management of one facility ruled out Continued Medical Education for lack of funds to invite teachers, in another facility, the medical superintendent provided short information leaflets to update staff on basic guidelines and procedures. Given that 10% of health donor funds are spent on training activities, there is a great need – but also opportunity – in policies that address these deficits.
Passive staff involvement versus active staff participation
Staff participation and staff involvement is an important HRM tool. It permits making the best use of health workers' knowledge, hands-on experience and ideas for improvements. In addition, staff participation involves recognition and appreciation of health workers and their competences. It appeals to their need to be taken seriously. This has important implications for motivation, both for the "will-do" component (e.g., self-realization, professional satisfaction) and the "can-do" component (e.g., self-confidence, improvements around the workplace by taking account of health workers' knowledge and ideas).
Most respondents in Kenya and Benin felt they could contribute ideas and efforts, particularly with respect to daily activities. While Kenyan respondents seem to see this happen primarily through staff meetings, Benin respondents rather refer to their efforts on the job.
By contrast, 57% of Kenyan respondents felt they couldn't participate in decision-making at their facility, a perception shared by nearly 80% of Benin respondents. There was no difference between the different provider types. Still, nearly everybody considers participation as important and, with a few exceptions, the vast majority would like to be involved much more actively. The respondents indicate that the relevance of participation consists in sharing one's views and knowledge of a situation or of a problem-oriented solution, to be involved in decisions that concern oneself or to react where necessary in order to avoid frustrations.
Interestingly, under current conditions hardly any feeling of professional satisfaction or self-realisation among respondents appeared to result from participation. Staff involvement appeared to be a passive undertaking. It serves to collect ideas and proposals. It allows staff to get informed rather than to take part in actual decision-making.
Given that health workers are socialized in a rather top-down, hierarchical organizational culture within the public sector, which ultimately reflects cultural values and characteristics of the wider society, the idea of participation as a means of self-realization and particularly of recognition appears now to be hardly present. This is not to say that there is not potential for participation to serve as a tool for motivation. As one respondent said explicitly:
"Participation is very important because a decision taken concerning yourself has an important effect on your motivation." (female nurse, 30 years, government facility, Benin)
The findings suggest that increased participation could have an effect on both the "can-do" component (ideas of staff are taken into account to improve the work process) and the "will-do" component (influence on decisions to the benefit of health workers – satisfaction with respect to personal goals, appreciation of health workers' skills and competences – satisfaction with respect to professional goals). Hence, there is a great need to institutionalize participation, e.g. by holding regular meetings, in which health workers not only share ideas and suggestions for improvements, but in which health workers ultimately participate in decision-making on issues that concern their work and immediate work environment.
Infrequent performance appraisals versus culturally adapted performance management
Performance management tools serve to improve performance of health workers. Performance management assists in setting, communicating and internalizing organizational goals, thereby nurturing the "will-do" component. At the same time, this provides feedback to health workers as regards their capabilities and skills to achieve these goals, hereby addressing the "can-do" component. One specific tool is performance assessment, which this section looks at specifically. Other tools include the communication of the organizational mission, vision and objectives, self-assessments, quality improvement teams, performance related payments, benchmarking and awards. Performance assessment constitutes a review of a health worker's skills and achievements.
In Kenya, government health workers must pass an annual performance review. The interviews revealed that not everybody appears to know what this is about and which indicators are applied. Attitudes regarding the relevance of the annual performance assessments seem to be mixed. Some health workers – especially those with a very good report – say it is motivating. Also, several think the performance assessment leads to a change in practice and behaviour. Yet, some few say that it has no effect on one's practice and behaviour. Moreover, less than 30% (27%) state that the performance assessment can potentially have an impact on one's promotion. A good assessment is required for a promotion, and even though bad assessments appear to be rare, promotions are not forthcoming, as they are contingent upon vacancies and the availability of financial resources. Also, as one respondent says,
"It is a slow and painful process; you have to follow up on the promotion you are meant to receive in Nairobi." (female nurse, government facility, Kenya, in focus group discussion)
Furthermore, individual award schemes at the district level ("best unit" of district health facilities), although carried out on the basis of a detailed performance assessment, were considered unfair and thus demotivating by the staff, probably because the method and criteria of the selection process had not been sufficiently communicated.
In contrast to Kenya, there are no such performance assessments in Benin. Instead, Benin respondents from the public sector referred to the biannual supervision process that serves to monitor key indicators. After the exercise, all facility managers in a district get together to receive feedback, advice and recommendations from the district health authorities, as well as congratulations in some cases. Health facilities are ranked, which allows health workers to find out about their relative facility performance. The majority of respondents report that that they know the procedures as well as the indicators by which facilities are monitored. However, according to some respondents, the responsible facility managers do not always share the results with the rest of the team, which is considered frustrating or annoying. In practice, the facility-based supervision process seems to be translated to the level of individual health workers and can hence be understood as a form of performance assessment.
Several health workers mentioned that good performance may be rewarded through participation in training or by means of a scholarship. However, on the whole, respondents appear to see no direct impact of good performance on career development. One positive effect are the so-called "primes de performance" (performance allowances), which are paid for good indicator results. The public ranking and public congratulations appear to have a strong effect on health workers. They create competition and provide motivation to perform, as indicated by the following two quotes:
"For the public results, you fight for being the best." (female nurse, around 30 years, government, Benin)
"These evaluations are a source of motivation for us; if you get a good grade, [...] we make even greater efforts to keep our rank or to go even further." (female nurse with management function, around 40 years, government facility, Benin)
On the other hand, it is also mentioned that the public ranking exercise may be very frustrating for those at the lower end of the scale.
By providing feedback on health workers' work, performance assessments have some effect on the "can-do" component overall, since they help improve knowledge and skills. Yet this effect is currently small, as is the effect on the "will-do" component. Although the responses suggest that health workers are performance-oriented, the potential of performance management as a motivating instrument has not been not fully realized yet. Given the fertile ground for performance orientation, there appears to be scope for the gradual introduction of a performance culture, the search for excellence. The responses also suggest that health workers are receptive to performance assessments. Any initiative to promote a performance culture must take into account cultural values, norms and characteristics, as shown by the following section.
Disincentives for individual success versus team-based performance promotion
The findings reveal certain cultural factors that may impinge upon motivation and performance. Respondents were asked whether there are barriers that impede personal efforts and act as barriers to better performance. They were prompted specifically on envy among colleagues. The following quotes give flavour of the responses given in relation to envy:
"Making efforts on your own creates envy and you will face obstacles." (female nurse, 33 years, government facility, Benin)
"Individual efforts are not sufficient; you need to share your élan with others, otherwise you are badly looked at, and you will have the problems of your life." (young male doctor, government facility, Benin)
"If someone tries to take on an extra responsibility, others say 'they are making life more difficult for us.'" (male medical superintendent, 27 years, government facility, Kenya)
"If one colleague tries to work hard, others gang up against him." (male clinical officer, 33 years, government facility, Kenya)
In Kenya, nearly half the respondents stated that individual efforts are appreciated, while 30% confirm that envy indeed impedes individual efforts. In contrast, only a sixth of Benin respondents, among them all the private-sector doctors, feel it is possible and worthwhile to engage in individual efforts. Yet, nearly two thirds clearly expressed that individual efforts are futile and that team efforts are necessary to reach further. Half of the respondents mentioned envy as a barrier to individual efforts.
With respect to performance management, such feelings and views are problematic, because they may lead individuals to discount outstanding performance and the acceptance of responsibilities beyond theirs duties. The development of a performance culture, based on individual efforts, appears to be closely circumscribed by the social context. The findings indicate that it may be necessary to build performance management schemes upon group identities. This requires a focus on building teams and creating team spirit. Likewise, this suggests designing awards for groups rather than for individuals, more so as the latter creates conflicts within facility teams.