Motivation and Stress:
A Discussion of Management Recommendations for a Local Hospital

The following report was written by a private consultant hired to examine the issues being experienced by Delmar General Hospital with their nursing staff. The report begins with a discussion of nursing, moves on to an overview of motivational theories, as well as stress and its effects on motivation. The issues occurring within this hospital with their nursing staff will be reviewed and interpreted by the private consultant. The private consultant will then conclude with a discussion of her final recommendations in terms of what can be done by Delmar General and their management staff to increase motivation and decrease stress levels, with examples from supporting research.
No matter what ones goal may be, motivation always plays a big role in achievement. In the workplace, individuals must be motivated to perform their best however, frequent conflicts can often hinder ones motivation levels by causing stress. Managers within the workplace can attempt to achieve maximum productivity while maintaining a positive employee affect through the use of various kinds of motivational plans.
The nursing profession is one of many within healthcare that deal with a lot of stress and motivational issues. Currently nursing is facing a series of issues that makes understanding stress and motivation very important for healthcare managers. It was estimated by the US Department of Health Human Services in 2004 that by the year 2020 there would be a shortage of between 400,000 and 1,000,000 registered nurses (Badgett, 2011). Nursing is in great need of individuals for many reasons. A majority of nurses are of the “baby boom” generation and have begun retiring, leaving a very wide gap among the nations nurses that will only widen as time goes on. In addition, nursing is becoming a career which is chosen less and less by the individuals that used to make up the entire profession; women. Decades ago women did not have as many options for employment as they do now; teaching, secretarial work and nursing were the main forms. The nursing profession needs to recruit and retain the nurses that do come into the profession and that includes creating a positive work environment (Burston, 2010). With the length of hospital stay continually reducing and the acuity level of patient illness increasing the need for more nursing care hours increases as skill level does as well, often causing an increase in stress and job dissatisfaction (Burston, 2010). Nursing needs to be seen as an interesting and compelling professionto a group of likely applicants than alternative professions and for these reasons it is important to study motivation and stress as it relates to nursing.
Motivation is a unique concept in that it is not a definitive feeling but more of a process that all individuals experience however, what causes the process to occur and the content can be very different from person to person. Motivation can be described as the conscious or unconscious incentive toward a goal directed behavior which may result from many different social or psychological factors (Reeve, 2009, p.3). Within the study of motivation there are two groups of motivational theories, content and process. Content theories work to explain the specific things that do the motivating while process theories focus on the cognitive processes underlying an individual’s level of motivation (Borkowski, 2009, p.105). Content theories help managers understand what activates employee behavior, while process theories help explain how an employee’s behavior begins, is altered and terminated (Borkowski, 2009). Employee motivation has a direct impact on a health service organization’s performance which makes it essential for managers to understand what motivates their employees. By understanding what motivates employees, managers can assist them in reaching their fullest potential in the workplace. There are some factors that can be controlled by managers such as various extrinsic factors (salary, working environment and condition, interpersonal relations) but there are also many intrinsic factors that can be significant (need for acknowledgment and attainment) (Borkoski, 2009, p.106). A good manager will use these factors as opportunities for employees to satisfy their personal needs while simultaneously satisfying the organization’s goals as well.
Motivational theories have their foundation in Maslow’s Hierarchy of Needs. The hierarchy contains five tiers which humans are driven to fulfill. The bottom tier is the most basic psychological needs like hunger and thirst. Once these needs are met an individual can move up to the next tier which is safety and security such as having a safe home, health/medical insurance, job security, etc (Reeve, 2009). Since employees are concerned about satisfying these basic or external needs, these motivators need to be addressed by employers and can be addressed by providing employees with sufficient benefits packages as well as salaries, etc (Borkowski, 2009, p.107). The next three levels of the hierarchy are more psychologically based. The third level is described as the desire to feel loved and/or approved by others which occur within the workplace when employees seek a sense of community and belonging amongst their coworkers (Borkowski, 2009, p.107). The need for approval applies to peers and managers alike. Managers can promote motivation by encouraging employees to feel connected to the organization and its goals which can in turn provide a sense of belonging and community. The next tier in the hierarchy is self-esteem; there is external esteem (satisfied through achieving the respect of others) and internal esteem (satisfied through self-respect, confidence and achievement) (Reeve, 2009). Self esteem grows when one receives attention and recognition from others for one’s accomplishment. Within this tier, cautious use of praise and encouraging feedback to workers is an essential means of motivating employees (Borkowski, 2009, p.108). The four levels just mentioned are described by Maslow as deficit needs because if any of these motivators are not satisfied, they create an inner tension within the individual that must be relieved. However if the individual has satisfied these needs, then they cease to motivate the individual and the person moves to the next and final level, which is the desire to reach one’s full potential as a person or self-actualization. Today, Maslow’s Hierarchy of Needs is used as a stepping stone for other motivational theories because it is evident individuals may not necessarily follow this hierarchy but may follow a mixture. While Maslow’s Hierarchy is not necessarily used today as an active motivational theory, it does show managers that not all employees are driven by the same needs and at the same time. The hierarchy can teach managers to recognize the needs of each employee.
There are many other motivational theories that have stemmed from Maslow’s Hierarchy: Alderfer’s ERG Theory, Herzberg’s Two-Factor Theory, and Job Design Theory; however the next theory discussed will by McClelland’s 3-Needs Theory of motivation. McClelland identified three types of motivational needs: achievement, power and affiliation. Achievement is described as the need to succeed and in general high achievers tend to seek moderately challenging tasks, take responsibility for their performance and require feedback to confirm their successes (Borkowski, 2009, p.118). Power is described as an individual’s need to influence others; however this can often be both positive and negative. Affiliation is an individual’s need to be liked and approved by others with a strong need for interpersonal relationships. McClelland believed that most persons have a combination of these motivational needs, with some exhibiting a stronger tendency to one particular motivational need (Borkowski, 2009, p.118). Like Maslow’s Hierarchy, this theory also shows managers that all employees are motivated by different things and that it is important as a manager to understand what motivates your staff.
The next few theories to be discussed are classified as process theories of motivation. The following theories are useful to managers within the healthcare system because they help to predict an employees’ behavior so that the behavior may be influenced by the manager. Expectancy Theory, developed by Vroom, suggests that for any given situation the level of a person’s motivation with respect to performance is reliant upon the employee’s desire for an outcome. The perception that an individual’s job performance is related to obtaining this want and the perceived likelihood that effort will lead to the required performance are also key motivational factors within this model (Borkowski, 2009, p. 127). In short, the force that drives a person to perform is dependent upon valence (strength of an individual’s need or dislike for a particular outcome), instrumentality (an individual’s perception that their performance is related to other outcomes) and expectancy (an individual’s perception that their effort will positively influence their performance) according to the Expectancy Theory (Reeve, 2009, p. 35). For managers, Expectancy Theory is very useful because it helps to understand a worker’s behavior. For example, if an employee lacks motivation, it may be caused by their indifference toward the existing outcomes. Expectancy Theory helps managers to think about what kinds of rewards their employees value most instead of assuming that all employees value the same rewards the same amount.
Equity Theory, states that a person evaluates their outcomes and inputs by comparing them with those of others. Equity Theory, developed by Adams, theorizes that social relationships can be viewed as transaction processes in which individuals make investments for which they expect certain outcomes. If there is relative equality between the outcome and investment of both parties to a transaction, then satisfaction is likely to result from the interaction. However, if inequality is perceived, then dissatisfaction can occur which then can cause tension and conflict within one or more individuals (Borkowski, 2009, p.131). With Equity Theory, inputs and outcomes are very important. In the workplace, an example of an employee’s inputs would be past job experience, education, skills, abilities, etc. Outcomes would be the things that result from the transaction such as salary, a promotion, recognition, bonuses, etc. Equity exists when the ratio of a person’s outcomes to inputs is equal to the ratio of a coworker’s outcomes and inputs. There are six methods that employees use to resolve possible inequalities: altering inputs, altering outcomes, cognitively distorting inputs or outcomes, leaving the field, distorting the inputs or outcomes of the comparison other and changing the comparison other (Borkowski, 2009, p. 132). Managers need to be aware of how employees perceive inequalities in the work environment. If employees perceive that they are not being dealt with fairly, it will become extremely difficult to motivate them.
Goal-Setting Theory discusses how individuals who are given specific, challenging goals usually outperform those who are given vague goals. Based upon this theory, Latham and Locke developed a goal-setting model with three steps to be followed: setting the goal, obtaining goal commitment and providing support elements (Borkowski, 2009, p. 136). Every goal set should be specific as well as measurable and should be attainable for the individual attempting to achieve the goal. Managers need to be conscious that seeking unattainable goals may cause employees to question management and experience dissatisfaction and frustration making motivation nearly impossible. If goal setting is to be successful, managers need to ensure that employees will accept and commit to the goals. Rewards of some form are used for completed goals and give employees a feeling of satisfaction and accomplishment for reaching a challenging, but fair goal. The successful completion of a goal works to reinforce acceptance of future goals. It is also imperative that managers ensure that employees have adequate resources to reach their goals, such as equipment, time, assistance, etc. This builds trust amongst employees that management is supportive of their efforts (Borkowski, 2009).
The final theory that will be discussed is Reinforcement Theory which is primarily based upon the work of B.F. Skinner. While Reinforcement Theory is not a motivation theory, it does help managers understand and influence behavioral change by use of reinforcements when necessary. In his research, Skinner found that an individual’s behavior could be modified through the use of reinforcement. In regards to the workplace, Reinforcement Theory suggests that an employee’s behavior will be repeated if it is associated with positive rewards and will not be repeated it if is associated with negative consequences (Borkowski, 2009, p. 138). There are four types of reinforcement that managers can utilize with their staff: positive, negative, punishment and extinction. For example, if a medical records employee is given the task of organizing and filing a stack of paperwork into charts and the paperwork and charts are filed correctly a manager can use positive reinforcement and give the employee praise or the manager can use negative reinforcement and not require the staff to work any overtime to finish filing. If the medical records clerk failed to file the paperwork and charts correctly a manager can use punishment and reprimand the employee or the manager can use extinction and eliminate a reinforcement that was previously being used. In this way managers can use the Reinforcement Theory to either reinforce or weaken an employee’s motivation to complete a specific task (Borkowski, 2009).
The six theories discussed above will all be used in the assessment of the issues being experienced by Delmar General, and will be consulted when final recommendations are made. All managers within Delmar General should familiarize themselves with the six theories as well. Before the issues being experienced by the hospital are discussed, stress within the healthcare industry and its effects on motivation must be made apparent. In the US, it is estimated that the cost of workplace stress is $300 billion annually by ways of absenteeism, reduced productivity and turnover (Buys, Mathews, Randall, 2010, p. 25). Work-related stress is a complex issue involving environmental, work life and personal factors. Due to the unpredictable environment healthcare professionals and staff are especially vulnerable to job-related stress. When effective reduction of stress is considered, it is important to recognize that both individual behavior and the sources of stressors will play a role. The issue is only perpetuated when stressed workers are de-stressed and then returned back to the work environment that contributed to their stress in the first place (Buys et al., 2010). Interventions made at the organizational level are therefore critical as many stressors can be somewhat controlled by employers and management such as: excessive work hours, health and safety risks, poor communication, job insecurity, workplace conflict, etc. All of the previous stressors mentioned are issues discussed previously that cause a decrease in workplace motivation. These factors, among others, taken together are reflective of the organizations environment, culture and climate. Improving the organizational atmosphere through encouraging management and a shared understanding of goals (e.g. goal setting theory) contributes to a positive work environment that is beneficial to good mental health and employee motivation (Buys et al., 2010).
Work environment can have big effect on stress and motivation levels. A study entitled “Employees’ Perception of the Management of Workplace Stress” was conducted by Buys et al. (2010) on the nursing work environment and its relation to nurse caring levels and motivation. The study gives some interesting ideas that can be used in the situation with Delmar General. Stress and burnout were found to be the main factors that negatively affected the level of nurse caring. Social interaction opportunities among nurses were shown to improve caring and as caring improved, patients seemed to experience health improvements as well. Understanding what is involved in nurse caring is critical to effective nursing management because nurses deal with patients so regularly. It is important that patients have a good experience and since patients in the hospital interact with nurses everyday they play a key role in how individuals perceive their level of care and the hospital as a whole. Researchers have found a predictive relationship between nurse caring levels and both patient advocation and patient satisfaction (Buys et al., 2010).
As applied to nurses and nursing work environments, research has shown that work-related stress detracts from nurse caring levels as we have already established. Stress related to work overload is negatively correlated with nurse job satisfaction, something that is being experienced within the nursing staff of Delmar General. A study done by Burton and Stichler (2010) used ideas from Maslow’s Hierarchy of Needs and Watson’s theory of human caring as the framework to understanding psychological motivations relevant to nurse caring. Nurses who are self-actualized conceptualize their work as a profession that enhances life significance (Burston & Stichler, 2010). The nursing work environment factors either promote or detract from their motivational needs. The environment promotes with compassion satisfaction and nurse caring satisfaction and detracts with stress, burnout and compassion fatigue (Burston & Stichler, 2010, p. 1828). The study was correlational and occurred at a 450-bed academic medical center in the southwest region of the USA. Their findings showed a statistically significant correlation between nurse job satisfaction, work-related stress and burnout and the outcome of nurse caring (Burston & Stichler, 2010). The implications of this study show how important it is for Delmar General to create a positive work environment.
With the motivational theories and issues surrounding stress in mind examining the issues occurring within Delmar General is the next step. In order to correctly assess these issues the management and organizations opinion concerning what is going on must be gathered as well as the nurse’s opinion. According to management the following changes have been observed with their nursing staff over the last year: significant decrease in work ethic, growth in absenteeism, decreasing bedside manner gathered from patient reviews and increased turnover. All of these issues have been mentioned above in the discussion on motivation and stress. After gathering the necessary information from management, the nursing staff was consulted. The following remarks and opinions were gathered from the nursing staff: they felt as if they were not acknowledged, were experiencing high levels of stress, dealt with lots of internal conflict, some of the nursing staff felt as if they were being treated unfairly (too many hours, too much work, no rewards or appreciation for their hard work), and the staff felt as if there was a lack of communication between the nursing staff and other staff. In order to effectively tackle each of these issues, the following sections of this report will deal with the problems individually with recommendations and supportive research.
The first issue to be addressed is the decrease in work ethic perceived by management and the reported decrease in good bedside manner from anonymous patient care surveys. Professional work ethic is reflected in the quality of care nurses provide to patients. Motivation is a key element in the professional work ethic and can be influenced by nurse self-reflection and management supports. In hospitals today, anonymous patient care surveys are being used more regularly and bedside manner is becoming an issue because not all nurses have a bedside manner that encourages and promotes healing. However, from a nursing stand point, this may be caused by increased stress felt by nurses due to understaffing and burnout. In order to address these issues managers need to engage individual nurses in a relationship based on trust, mutual responsibility and common purpose (Badgett, Cazier, Chanta, Dave, Dotson, 2011). This works to empower nurses so individual talents and skills can be used to provide quality care to all patients on the unit. This shared goal of high-level care between nurses and nurse managers ensures that all parties have a common understanding of the importance of high-quality patient care. This involves nurse manager to consult the appropriate nursing staff for making patient care decisions (Badgett et al., 2011). This promotes participative management in which individual nurse’s input is considered. This can be done by implementing effective communication through a combination of active listening, mutual reflection and dialogue between the nurse and manager. This non-confrontational approach not only motivates the nurse to provide excellent care, but it also builds interpersonal relationships between the nurse and manager. However there are certain things that are essential for this method to be successful. A continual feedback system must be developed between nurses and managers, as well as all other staff. The continual feedback system should result in positive changes that ultimately lead to feelings of accomplishment. As a result, the need to reinforce this positive behavior increases motivation and a strengthens work ethic (Badgett et al, 2011). Another important aspect to this issue is leadership; an effective manager must be educated in leadership techniques that maximize the potential of the nursing staff. Effective nurse managers should be aware of the unit dynamics but be able to lead in a way that makes all nurses feel motivated to work with their peers to resolve a conflict. Managers that classify themselves as high achievers according to McClelland’s 3 Need Theory, are the least effective and actually result in de-motivating workers (Badgett et al., 2011). If Delmar General wants to introduce effective leadership skills to their managers then it is recommended that they partake in leadership training sessions. Another way in which managers can improve work ethic and bedside manner is by going beyond the typical periodic review and into a discussion with nurses reflecting on their bedside practice with managers encouraging and offering organizational supports in order to confirm high quality care. This is essential because the nurse may not even realize that their bedside care is being received poorly. Another way to help identify primary sources of inspiration for nurses is to initiate reflection by means of journal clubs or retreat experiences for nurses and managers alike (Badgett et al., 2011). With the correct instilment of the methods mentioned in this section, managers should see an improvement in work ethic and also may see some improvements in other problem areas.
To address issues surrounding workplace stress, perceived lack of acknowledgment and rewards the following ideas are recommended which are based upon a study done in a hospital in the southern US on their nursing staff. The study done by Badgett et al. (2011) surveyed the nurses to determine their perceptions of reward models currently active within their hospital. The results showed that nurses with a high degree of intrinsic motivation are more satisfied with extrinsic rewards. In turn, using the correct kinds of rewards for nurses can increase job satisfaction and factors that lead to greater satisfaction can reduce nurse turnover which will then help reduce the nursing shortage within the hospital (Badgett, et al., 2011). Intrinsic motivation consists of self-determination and self interest. These factors make work fulfilling and are a major reason why individuals star at a job. These factors also work to keep stress levels down. When one is motivated to work to complete a task more for internal satisfactions or as a tool for self-fulfillment as opposed to extrinsic work motivation then the extrinsic rewards may not do much to motivate them (Badgett, et al., 2011). However by performing staff surveys and determining which staff members are motivated extrinsically, which is when an object or event is received or experienced during or following the completing of a task, managers can know when rewards such as promotions, salary increases or even simple luncheons or special breakfasts are in need for increasing motivation. Not only will this increase motivation with the nursing staff but will also give them a sense of accomplishment and acknowledgement. However the study also revealed that nurses have different levels of satisfaction with the intrinsic rewards of nursing. Small differences in intrinsic reward scales resulted in a much larger amount of dissatisfaction with extrinsic rewards, especially concerning pay issues. This suggests that by finding ways to improve intrinsic motivation, hospitals may not have to invest so much in financial resources to keep nurses satisfied and on the job (Badgett et al., 2011).
Issues surrounding conflict in the workplace are another problem being experienced within the nursing staff. In a study conducted by Haraway & Haraway in 2005 on conflict-management and resolution training supervisors and managers within healthcare participated in conflict-management strategy session. Conflict can result from organizational changes, miscommunications, scarcity of resources, prejudices and value incongruence (Haraway & Haraway, 2005). Conflicts should be productively managed in an effort to increase effectiveness and efficiency because unmanaged conflict can cause negative, unintended consequences. Unmanaged conflict creates physical, psychological and behavioral stress in the workplace, causing high costs to turnover, absenteeism and loss of productivity. These are the things that are taking place with the nursing staff at Delmar General. The study found that current conflict management strategies of choice among physicians and nurses tends to be either adversarial or avoidant, both are inefficient and do not resolve the conflict properly (Haraway & Haraway, 2005). Nurses have been found to practice avoidance above all other strategies. When individuals choose avoidance, they may be reacting due to a lack of knowledge. This is why on-the-job training provided by trained managers that possess knowledge and skills in workplace conflict can give them alternative strategies. Conflict-management training can increase organization effectiveness and efficiency by reducing job-related stress. The training can reduce workplace stress by providing interpersonal awareness and skills. For the conflict resolution training it is recommended that managers and supervisors attend a series of conflict-management training sessions, which can be scheduled and held multiple times due to scheduling conflicts that may arise if only session is given. In the study done by Haraway & Haraway (2005), participants that completed their conflict-management training felt better equipped to handle conflict within their workplace and the numbers provided the statistical data to back this up (Haraway & Haraway, 2005). Since this can be a continuing problem it is recommended that an ongoing staff development program be instilled with conflict-resolution and management training included.
In an article entitled “An Assessment Tool For Developing Healthcare Managerial Skills and Roles” (2003), Kristina Guo goes in depth into the various skills and methods that can be used by healthcare managers to effectively manage in the healthcare industry today. In the article, Guo (2003) goes into the ways in which managers must possess the skills needed to fill various roles such as: strategist, communicator and delegator. She goes on to describe that multiple roles must be employed by a manager because a single management role will not suffice in the complex situations faced by managers today. This is especially true when discussing issues of nursing. Managers today must be able to examine a situation and assess it from different perspectives and address it through these multiple roles (Guo, 2003). This is true with the nursing managers at Delmar General, who are dealing with a short staffed, over worked nursing unit. As a result of the many challenges faced by today’s healthcare managers, Guo (2003) conducted a study in order to discover the multiple roles needed for today’s challenging healthcare environment. The study uncovered six major roles which include: leader, liaison, monitor, entrepreneurial strategist, disturbance handler and resource allocator. These six roles are a great way to sum up the roles that managers at Delmar General should be fulfilling. The role of leader includes interpersonal relations, and providing purpose to motivation for staff. As a liaison, managers should serve as the link between the environment and the organization. The manager as a monitor serves to gather information and seeks to identify problem areas as well as ensuring that operations run smoothly and using the collected information to seek and understand changes taking place in and out of the organization. As an entrepreneurial strategist, management should be willing to take risks by investing in new projects. Next, managers must work as a disturbance handler, meaning that they should be dealing with conflicts effectively and efficiently and lastly as a resource allocator (Guo, 2003). According to Guo (2003), managers that cannot fulfill a particular role must take steps to acquire or improve the respective skills and roles. These six suggested important roles for healthcare managers should be used as guidelines by the management staff of Delmar General.
It is important that Delmar General look into implementing each suggestion however it is understandable that it may not be practical in the current hospital setting. The first final recommendation is that managers within Delmar General construct a survey for their nursing staff in which motivational factors can be determined; managers may also hold a meeting where this is discussed instead of developing a survey. This will be useful in determining what managers can do to motivate all of the nursing staff. As discussed earlier with McClelland’s 3-Need Theory and Reinforcement Theory, it is important to find what kind of stimulus motivates staff. Managers may find that a simple acknowledgment, time off, promotion, salary increase, or just a special luncheon in honor of an achievement may be what the staff is looking for to increase motivation. Not only will the instilment of these rewards increase motivation for staff members but it will also make the nursing staff feel as if they are appreciated for their hard work, this may help them to feel as if they are treated more fairly as well as decrease stress. In accordance with a reward system, a new goal setting system will enable managers to motivate staff. Managers must be educated on the Goal-Setting Theory and can utilize it in their organization by setting clear and attainable goals with their nursing staff that may end in a reward for the staff or recognition to a specific staff member or group. Not only will this motivate staff but it will also increase work ethic. Using specific goals for the nursing staff will also work to build team morale within the department. To reduce workplace conflict it is recommended that managers and supervisors attend conflict resolution training sessions in order to assist the nursing staff with their various issues. Biweekly or monthly staff meetings with the nursing staff as well as physicians will assist in communication issues. During these meetings physicians can be made aware of the various issues that the nursing staff is dealing with, including the work overload and lack of sufficient nurses. Managers should make themselves available at all times, even when they are not in the office (by email or phone) to the nursing staff so that they always have someone with the ability to solve problems to bring their issues to. A day conference for the nursing staff would be a great opportunity for any continuing education that managers or nurses feel they need. In order to make sure their programs are successful, the management staff at Delmar General should create follow up surveys and various forms of feedback so that the nursing staff can give their opinion about what tactics work best so that the management staff can edit the programs to best fit the needs of the nursing staff and the organization. These methods will take a lot of time and effort for Delmar General to initiate however once these tactics are instilled the management will notice a significant decrease in work place stress among nurses and an increase in motivation that will then increase productivity as well as the level of care and overall success of the nursing staff.

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