THE ROLE OF MANAGEMENT IN PROMOTING A MOTIVATIONAL WORK SETTING FOR NURSES

The use of motivation and reward strategies is necessary for empowerment of staff members in their work situation. For motivation to occur in a health service, strategies should focus on self-motivation, expansion and enrichment of tasks, acknowledgement of work performances of nurses, rewards for outstanding service and constructive feedback by managers to nurses. A descriptive, explorative study was done to investigate the current motivational strategies used in health services management settings. A sample of 112 nurses completed a questionnaire that provided information relating to the employer/health service (organisational culture, personal values and expectations), the direct supervisor of a staff member (working relationships, interpersonal skills of the supervisor) and self-concept. Important strategies that should be employed by managers in the establishment of a motivational environment for staff are integrated into a conceptual framework. The framework lends itself for planning of future in-service training of nursing staff members. Special attention will be given to the following nursing management principles: • • • • Nurses have to play their own role in the attainment of their personal objectives. Open acknowledgement of work performances of nurses is a priority. Nurses require support and positive feedback that fosters a feeling of self worth. Job descriptions should not prevent staff from moving beyond their core tasks. • Change is needed in creating a new organisational climate that favours remuneration. Based on the findings of this research study, the researcher sets out to illuminate the aspects fundamentally involved in maintenance of a motivational working climate for nursing staff members.

A descriptive, explorative study was done to investigate the current motivational strategies used in health services management settings.A sample of 112 nurses completed a questionnaire that provided information relating to the employer/health service (organisational culture, personal values and expectations), the direct supervisor of a staff member (working relationships, interpersonal skills of the supervisor) and self-concept.
Important strategies that should be employed by managers in the establishment of a motivational environment for staff are integrated into a conceptual framework.
The framework lends itself for planning of future in-service training of nursing staff members.Special attention will be given to the following nursing management principles:

• • •
• Nurses have to play their own role in the attainment of their personal objectives.
Open acknowledgement of work performances of nurses is a priority.
Nurses require support and positive feedback that fosters a feeling of self worth.
Job descriptions should not prevent staff from moving beyond their core tasks.
• Change is needed in creating a new organisational climate that favours remuneration.
Based on the findings of this research study, the researcher sets out to illuminate the aspects fundamentally involved in maintenance of a motivational working climate for nursing staff members.

BACKGROUND AND RATIONALE
It is claimed that the word "motivation" is amongst the six most used words in company documents.Just because it is used, does not mean to say that it is understood or effectively implemented in an institution (Denny, 1994:7).In 1999 the following research priorities To motivate others is one of the most important tasks of management.Those who have the greater responsibility of managing or leading others should know what is necessary to help people achieve their own aspirations or how they can be motivated towards a common goal (Denny, 1994:9).It comprises the ability to communicate, to set an example, to challenge, to encourage, to obtain feedback, to involve, to delegate, to develop and train, to inform, to brief and to provide a just reward (Denny, 1994:7).
Motivation is also generally defined as "the arousal, direction, and persistence of behaviour" (Daft & Lloyd, 2000:300).Studies on motivation thus concern what prompts people to initiate action, what influences their choice of action, and why they persist in doing it over time.This study was aimed at identifying important motivational needs of higher and lower levels of nurses/ managers that should be addressed in the future health services management situation.
If an organisation does not possess the ability to motivate its employees, the knowledge within the organisation is not practically used to a maximum.Therefore, it should become the aim of every successful organisation to find the factors that enable it to motivate its employees to continuous growth and learning and to take advantage of this knowledge to ensure its living (Osteraker, 1999:73).

PROBLEM STATEMENT
The overall research question could thus be stated as follows: What are the most important motivational needs of nurses in their work environment and how should they be addressed?

LITERATURE STUDY
The findings of various research studies outline important motivational variables in the work situation of health care professionals: • Applebaum and Kamal (2000:733) indicates the affect of job enrichment, employee recognition, pay equity and managerial skill on the job satisfaction and motivation of employees.

•
A recent factor analysis identified a group of factors including recognition and appreciation, salary and remuneration, promotional status and job satisfaction (Analoui, 2000:324).
A survey on motivating staff, conducted in Nigeria reveals that a general dissatisfaction regarding training 16 opportunities, sabbatical leave, communication and management style, work environment and promotion prospects exists (Abifarin, 1997:124).
Another study outlines the environmental factors that impact on motivation of staff as approaches to financial rewards, the culture of staff development, the diversity of staff experience and roles, personal autonomy and organisational structure (Rowley, 1996:11).
A research study explored what motivated employees according to over 40 years of motivational surveys (Wiley, 1997:263).The comparisons revealed that employees' motivational preferences vary over time.The results of the latter study indicated that the factors that motivate today's workers are more extrinsic than they used to be.
Employees in the mentioned study overwhelmingly selected "good wages" as the top motivator.A good wage is an extrinsic reward with intrinsic potency.On the surface "good wages" seem to be purely extrinsic.Yet,

Feedback
To find (an) answer(s) to the overall research question, it was decided that a quantitative, descriptive, explorative study was the most appropriate method.The purpose of exploratory research is to gain insight into a situation, phenomenon, community or person (Bless & Higson-Smith, 1995:42-44).A research instrument in the form of a Likert-type questionnaire was developed.
Ten expert nurse managers as well as a statistician critically evaluated the instrument in a pre-test.These nurse managers did not participate in the main study.From an item analysis on the research data, a Cronbach alpha (a) of 0,839 was obtained, indicating a reasonably reliable instrument (Guy, et al. 1987:171).

LIMITATIONS AND ETHICAL CONSIDERATIONS
The following limitations were identified in this study: • The choice of the Gauteng Province under study was based on non-probability sampling, which limits the generalisation of the findings.

•
The findings relate to a small size of only 112 health services management students that may not be representative of the entire population of students registered for the practical course in Health Services Management II.
Ethical issues were taken into consideration.Participants were ensured of anonymity.Informed consent was obtained before the questionnaires were completed.All partiCipation was voluntary.

RECOMMENDATIONS
General background of the respondents    A principal component factor analysis with a Varimax rotation on the 60 items of section B of the questionnaire regarding the employer, lead to interesting findings.
Seven key factors were identified as areas of satisfaction or dissatisfaction in the health service (table 3).

Job dissatisfaction in health services
Areas of dissatisfaction (table 3) were identified as: strategic planning (Factor 1), autocratic managemenV rules (Factor 2), financial management (Factor 3) and strict discipline (Factor 4).According to Hertzberg'S Two- The respondents were well represented in all spheres Factor Theory, areas of dissatisfaction are called Hygiene of the nursing service namely teaching, hospital wards, factors (Dienemann, 1998:361-362).nurse managers find it nearly impossible to make rapid changes or decisions because of a morass of policies, forms, procedures and committees (factor 2); management ought to be more approachable at all times (factor 2); the service pays some of the highest salaries at a given level to the recently hired (factor 3); and the service awards the largest budget increases and new staff positions to those who spend the most (factor 3).
The above mentioned factors are important because they reduce job dissatisfaction, but they will not result in an increase in satisfaction/motivation (Dienemann, 1998:361 ).when supplemented with an income that allows employees to meet physiological and security needs for themselves and their families.By doing so productivity of existing and potential employees is increased (Applebaum & Kamal, 2000:733).

Job satisfaction in health services
Culture is the set of key values, beliefs and understanding shared by members of the organisation (Daft & Lloyd,   2000:44).Each organisation requires a culture that supports the mission and objectives of the organisation.
In a recent study of Minnaar (2001 :205) only 46% of respondents indicated that the culture in their hospitals was one of caring in which people were inspired to work.
As human beings we all long for an experience at work that we can feel that "wow" experience that inspire humans.Hospitals and health care settings should provide environments for health professionals and workers to be inspired towards growth, development and motivation in their professions.The key success factors basic to the successful growth and survival of the institution were identified in factors 5, 6 and 7 -the motivators.
The three main areas of satisfaction in the health service were identified as motivational factors namely: responsibilities (Factor 5), the work itself (Factor 6) and personal growth and belonging (Factor 7).
It is the motivators (e.g. the job challenges, autonomy, responsibility) that are the basis for the feelings of job satisfaction (Dienemann, 1998:361).Respondents were of the opinion that job satisfaction in the work place is promoted by the following:

Concepts
• Recognition • High status • Does preferred work • Self-respect

• Safe work • Good working conditions
Significant differences between the expectations of nurses on the higher and lower levels in the hierarchy were found to exist in health services with regard to motivational and reward concepts in the working environment (table 8), Respondents were asked how much they would care if certain motivational concepts in their working environment were greatly reduced: • It seemed thatthe higher the position of a nurse in the organisational structure (61 % top level managers), the more self respect as a higher order motivational need was perceived as The same tendency was found in the item regarding recognition, More higher level nurses (61%) than lower level nurses (38%) were of the opinion that recognition was an important higher order motivational influence in the working environment (X2 = 7,04, P < 0,05), Only a small number of lower level nurses versus approximately half (42%) of the higher level nurses were of the opinion that high status is important as a motivational concept in the working environment (X2 = 13,33, P < 0,01), A vast majority of approximately 91 percent top level nurses valued the participation in decisions as very useful versus only 30 percent of the lower level nurses.It seems that the higher level nurses have more opportunities to concentrate on tasks they preferred doing (X2= 12,66, p< 0,01).Percentage of nurses/managers (N=112) It is interesting to note that the higher the level of the nurse in the hierarchy of the service the more important they acknowledged higher order motivational needs such as recognition, self respect, participation in decisionmaking and high status in their working environment.
This could be due to fulfilment of their basic motivational needs on the lower levels of Need theory.It thus seems that the lower the position of a nurse in the hierarchy the more lower order motivation and incentive needs are viewed as important.In a research study done in 1999 it was found that most senior professionals had unfilled needs only at higher levels of the needs hierarchy.It was also pointed out that an individual's exact level on the HEALTH SA GESONDHEID VoL7 No.2 -2002 needs hierarchy will vary from person to person with differences between supervisors and their staff.A number of research findings have suggested that managers are, in general, more satisfied with and motivated in their jobs than are workers/subordinates (Oshagbemi, 1999:108).

The general working situation
In more significant differences between the opinions of respondents working in the public and private health sectors, on the motivational concepts in their working environment, the following were identified: The respondents working in private health institutions (51 %) were much more positive towards the motivational concept of doing preferred work than their counterparts (27%) working in the public sector (X2 = 7,36, p< 0,05).
Only sixteen percent of the respondents working in the public sector versus 33 percent of their colleagues in the private sector acknowledged the fact that nurses have a need for safety in their current working situation (X2 = 6,52, P < 0,05).
The same tendency was found in the item re-  The importance of responsibility is also pointed out in a very recent study on career motivation, where Leung and Clegg (2001 :12-20) found that younger executives had higher levels of job motivation and were striving to attain additional responsibility and authority in work assignments.On the other hand senior executives were more concerned with holding on to their previous accomplishments and competence in their occupational role.
The concept of good working conditions, is closely linked with the importance of corporate wellness programmes.
Organisations in Singapore and elsewhere have begun to successfully implement wellness programmes on an organisation-wide scale with emphasis on a healthy lifestyle and improved health of employees and the broader public.Findings from a research study undertaken in Singapore in 1997 indicate that employees in organisations with wellness programmes generally have a more positive and motivated attitude towards their organisations and express higher job satisfaction (Ho, 1997:177).The point I would like to make is that 22 management should not hesitate to adopt health promotion activities in the workplace.
In this study, the 112 respondents identified the least important motivational concepts in the working environment as self-guidance, food and clothes, and high status (table 10).It was interesting to note that in the findings from a study undertaken in Russia and Poland the two most important motivators to employees were pay and friendliness of co-workers.In most cases, managers' perceptions of job motivators were similar to their employees (Huddleston & Good, 1999:383).These motivators are focussed on the lower levels of the needs theory.

Rewards and the job
Respondents were asked to indicate the important personal values and expectations of their job.Responses on the personal values and expectations of the job were analysed according to extrinsic and intrinsic rewards (table 11).
Table 11 indicates the number of respondents who allocated the highest value of seven (7) to the most important values and expectations of their daily job.An intrinsic reward is the internal satisfaction a person receives in the process of performing a particular action (Daft 1999:239).Individual rewards were identified as Extrinsic rewards are given by another person/supervisor and include promotions and pay increases (Daft, 1999:239).In this study the system wide rewards were identified as loyalty (as being part of a winning organisation) and economic security.System-wide rewards apply the same to all nurses within an organisation or department (Daft, 1999:239).Although this study did not focus on it, managers in different career stages could have distinct intrinsic and extrinsic reward preferences that may ultimately affect motivation and productivity.It is important to keep in mind that the perceived importance of various rewards for staff could be influenced by their career stage.This issue could be addressed in future research studies.• More attention should be paid to incentives and rewards for outstanding service.Expert individuals can receive an incentive by giving them the choice which project should be started next (Kanter, 1989:91).New incentive programmes can be introduced in health care settings that will lead to economic security, personal development, health, self-respect and loyalty of nurses.
• Constructive feedback by managers to nurses should be a priority.According to Kinlaw (1995:78) motivated individuals require more frequent feedback about their work performances.Managers should talk with staff members on a regular basis (interaction) and should be able to carry out on-the-spot assessments, listen to and praise staff as the case may be (Abifarin, 1997:124).
for the new millennium was identified by the Research Committee of the Democratic Nursing Organisation of South Africa (1999) following input from various sources: relate to the importance of the role of the health services manager in motivation of health care employees.Motivation is a key ingredient in achieving an effective and successful body of staff members in any health organisation.However, the current situation in health services indicates concerns in which nurses could experience a lack of motivation in their work environment.Klann (1992:20)  points out that a tendency in the last twenty years is the decreasing of authority and autonomy of nurses in health services.The latter does not contribute to a motivated workforce.The restructuring of the economy and transformation in some countries, directly challenge the manager's task in motivating employees by increasing the sense of job insecurity and eroding the concept of company/institutional loyalty(Gee & Burke,   2001 :131).Cooper (1999:569) is of the opinion that work is increasingly changing into a short-term contract culture, with long hours, intrinsic job insecurity and declining sense of loyalty by employees to their employer.The impact on the employee's health, the family and the health sector as the "bottom line" is great.A time for reflection is needed in the way we manage people's HEALTH SA GESONDHEID Vol.7 No.2 -2002 careers and futures.Motivated nurses are needed to actively participate in organisational activities to ensure quality nursing care, cost effective service rendering, high morale and work productivity.
Province of South Africa viewed their motivational needs in the working situation.On the one hand, nurses need continuous motivation in their work situation to experience job satisfaction.On the other hand nurses have different motivational needs in their working environment

Figure 1
Figure1illustrates the conceptual framework of the motivational process that directed the research(Jooste, 1997).The three key components of the framework are the employer (work environment), the direct supervisor/ manager and the self concept of the nurse that contributed to self motivation, expansion and enrichment of tasks, acknowledgement of work performances of nurses, rewards for outstanding service and constructive feedback.This article focuses on the role of the employer in motivating nurses in their work situation.

Face
and content validity were ascertained through experts in the field of Health Services Management who critically reviewed the questionnaire and suggested a few improvements thereof.The final draft of the questionnaire was administered to HEALTH SA GESONDHEID Vol.7 No.2 -2002 all 112 second year students who were attending the laboratory workshops on Health Services Management II of the University of South Africa (Unisa) in the Gauteng Province.The total population was represented by 448 second year students registered for the second year practical course in Health Services Management.Convenience sampling was used and 112 second year students participated in the research study.In this sampling the researcher selected those respondents who were "close at hand" during the workshops and time and effort were saved."What was lost in accuracy was gained in efficiency"(Guy, Edgly, Arafat & Allen, 1987:189).Conclusions were drawn from the available responses that could influence the generalisability of the findings of the study to a broader population of health services managers in the Gauteng Province.The 120 items in the questionnaire were based on the three components of the conceptual framework, namely the employer (working environment), the direct supervisor/manager and the self concept of the nursein establishing an effective motivational environment for nurses.Content validity was tested by the fact that the items represented the conceptual framework of the study.
of the respondents worked in the public sector (table 2).It is well known that the private sector is more focussed on participative management and motivation than the public sector.

Figure 3 :
Figure 3: Disciplines/working situation (N = 112) factors are poor, work is dissatisfying.Good strategic planning, rules and effective financial management will therefore remove the dissatisfaction among nurses, but they do not in themselves cause nurses to become highly satisfied and motivated in their work.Respondents were of the opinion that dissatisfaction among nurses in the health service was due to the lots of people in motion but not much is getting done (factor 1); management believe that the way the organisation has always done a job is the only way to do it (factor 2); the service has trouble with political games and backstabbing when it comes to salary raises, promotions and perks (factor 2); Some research studies indicate that income/money/pay is a moderating factor with regard to the success of nonmonetary incentives.Findings indicate that recognition, HEALTH SA GESONDHEID Vol.7 No.2 -2002 job enrichment and job satisfaction are most effective working climate Satisfaction creates confidence, loyalty and ultimately, improved quality in the output of the employed (Tietjien & Myers, 1998:226), garding good working conditions.Nearly two thirds (66%) of respondents working in the private sector versus only 42 percent of respondents employed in public health services viewed good working conditions as an important motivator in their work situation (X2 = 6,68, P < 0,05).It seems that the respondents employed in the privatesector attach more value to certain motivational concepts such as does preferred work, recognition, safety and good working conditions than their counterparts working in the public health institutions.The above responses indicate that the majority of motivational needs of the respondents exist on the safety and esteem levels of Maslow's Theory.According to Du Rand and Vermaak (1995:29) individuals who experience inadequate recognition experience a lack of motivation.It was also suggested that attention should be given to the job satisfaction of nurses and the acceptance of nurses as unique human beings.Respondents (n=112) were also asked to identify the five most important motivational concepts needed in their work situation in sequence of importance (table9 rewards may differ among nurses within the same organisation.An extrinsic, individual reward should be seen as a bonus, where an intrinsic, individual reward would be a sense of self-fulfilment that a nurse derives HEALTH SA GESONDHEID Vol.7 No.2 -2002 from her/his own work.

RECOMMENDATIONS
From the responses regarding the working environment and the management structure it is clear that specific motivational needs should be addressed by specific motivational systems.In future strategies for the motivation and empowerment of nurses, supervisors should focus on the following (figure 4): • • Promotion of self-motivation strategies and acknowledgement of work performances of nurses are essential to address the belonging and personal growth needs of nurses.Drew (1992: 18) is also ofthe opinion that it is important to acknowledge the quality of nursing behaviours and quality performances.Corporate pep talks can be useful.The need for responsibilities, recognition and high status should be fulfilled.Expansion and enrichment of tasks, giving more new and creative responsibilities along with authority should be emphasised.Hereby nurses' HEALTH SA GESONDHEID VoL7 No.2 -2002 needs regarding work itself, doing preferred work, good working conditions and safety are addressed.

Table 1 :
Years in current position

Table 2 :
Type of service

Table 6 :
Items with significant values regarding organisational culture

Table 8 :
Significant differences in opinion between

Table 9 :
The value of motivational concepts in the work environment -important concepts (N = 112)

Table 10 :
The value of motivational concepts in the work environment -least important aspects (N = 112)

Table 11 :
The value of motivational concepts in the work environment -important concepts (N = 112)