University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA MOTIVATIONAL FACTORS INFLUENCING WORK PERFORMANCE OF NURSES IN EASTERN REGIONAL HOSPITAL, KOFORIDUA BY MIRIAM ALORZUKEY (10405817) A LONG ESSAY SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF BUSINESS ADMINISTRATION (HEALTH SERVICE MANAGEMENT OPTION) DEGREE JUNE, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I do hereby declare that this work is as a result of my own research and has not been presented by anyone for any academic award in this or any other university. ……………………………………. …..……………… MIRIAM ALORZUKEY DATE (10405817) i University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I hereby certify that, this long essay was duly supervised in accordance with procedures laid down by the University. …………………………. ………………………….. DR LILY YARNEY DATE (SUPERVISOR) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this project to the Almighty God for granting me knowledge and understanding to carry out this study. I also dedicate this work to my parent, Mr. Anthony Alorzukey and Mrs. Happy Alorzukey, my Siblings Mildred, Miranda, Samuel, Ross and Elijah Alorzukey and my Pastor, Rev. Henry Osei Amoako for helping to make this journey a success. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am very grateful to the Almighty God for seeing me through my studies. I wish to express a heartfelt gratitude to my supervisor, Dr. Lily Yarney for her guidance and constructive comments throughout the study. Again, I wish to thank all the lecturers of the Department of Public Administration and Health Services Management of the University of Ghana Business School. I am also grateful to my family, friends and loved ones for their encouragement and support during my course work. My sincere acknowledgment finally goes to the staff and management of Eastern Regional Hospital especially the nurses for their time and patience during the data collection exercise, I say God bless them. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Contents Pages DECLARATION ................................................................................................................... i CERTIFICATION ................................................................................................................ ii DEDICATION .................................................................................................................... iii ACKNOWLEDGEMENT ................................................................................................... iv TABLE OF CONTENTS ...................................................................................................... v LIST OF TABLES ............................................................................................................ viii LIST OF FIGURE(S) ........................................................................................................... ix LIST OF ABBREVIATIONS ............................................................................................... x ABSTRACT ......................................................................................................................... xi CHAPTER ONE ................................................................................................................... 1 INTRODUCTON .................................................................................................................. 1 1.0 Introduction ................................................................................................................. 1 1.1 Background to the Study ............................................................................................. 1 1.2 Problem Statement ...................................................................................................... 4 1.3 General Objectives ...................................................................................................... 7 1.3.1 Specific Objectives ............................................................................................... 7 1.4 Research Questions ..................................................................................................... 8 1.5 Relevance of the Study ................................................................................................ 8 1.6 Organization of the Study ............................................................................................ 9 1.7 Definition of Terms ..................................................................................................... 9 1.8 Chapter Summary and Conclusion ............................................................................ 10 CHAPTER TWO ................................................................................................................ 11 LITERATURE REVIEW.................................................................................................... 11 2.0 Introduction ............................................................................................................... 11 2.1 Concept of Motivation: Definition and Overview .................................................... 11 2.2 Forms of Motivation .................................................................................................. 14 2.2.1 Intrinsic Motivation ............................................................................................ 14 2.2.2 Extrinsic Motivation ........................................................................................... 16 2.3 Performance Management Parameters of Performance ............................................ 16 2.3.1 Ways to Measure Work performance ................................................................. 18 v University of Ghana http://ugspace.ug.edu.gh 2.4 Performance in the Health Sector .............................................................................. 19 2.4.1 The Effect of Motivation on Performance of Nurses ......................................... 21 2.5 Proposed Hypothesis ................................................................................................. 22 2.6 Empirical Evidence ................................................................................................... 23 2.6.1 Factors of Motivation.......................................................................................... 23 2.7 Theoretical Framework ............................................................................................. 24 2.7.1 Maslow’s Hierarchy of Needs Theory ................................................................ 24 2.7.2 Herzberg’s Two-Factor Theory .......................................................................... 25 2.7.3 Vroom’s Expectancy Theory .............................................................................. 27 2.8 Conceptual Framework ............................................................................................. 27 2.9 Chapter Summary and Conclusion ............................................................................ 28 CHAPTER THREE ............................................................................................................. 29 RESEARCH METHODOLOGY ........................................................................................ 29 3.0 Introduction ............................................................................................................... 29 3.1 Research Design ........................................................................................................ 29 3.2 Sources of Data ......................................................................................................... 30 3.3 Study Setting ............................................................................................................. 30 3.4 Study Population ....................................................................................................... 31 3.5 Sampling Technique .................................................................................................. 32 3.5.1 Sampling procedure ............................................................................................ 32 3.5.2 Sample size determination .................................................................................. 33 3.6 Validity and Reliability ............................................................................................. 33 3.7 Data Collection Method ............................................................................................ 34 3.8 Data Processing and Analysis ................................................................................... 35 3.9 Ethical Consideration ................................................................................................ 36 3.9.1 Chapter Summary and Conclusion ..................................................................... 36 CHAPTER FOUR ............................................................................................................... 37 PRESENTATION AND ANALYSIS OF DATA .............................................................. 37 4.0 Introduction ............................................................................................................... 37 4.1 Background to the Analysis ...................................................................................... 37 4.2 Demographic profile of Respondents ........................................................................ 37 4.3 Motivational Factors for work Performance ............................................................. 39 vi University of Ghana http://ugspace.ug.edu.gh 4.3.1 Intrinsic motivation ............................................................................................. 39 4.3.2 Extrinsic Motivation ........................................................................................... 41 4.4 Motivational Factors that Influence Nurses’ Performance ........................................ 42 4.5 Regression Analysis of the Effect of Motivation Factors on Work Performance ..... 43 4.6 Other Incentives and Benefits that Influence Work performance ............................. 44 4.7 Top management Involvement in Decision Making ................................................. 45 4.7.1 Expectations from Current Job ........................................................................... 45 4.7.1.1 Compensation and Reward Packages........................................................... 46 4.7.1.2 Good Work Conditions ................................................................................ 46 4.8 Top management interest in Motivating Workers ..................................................... 47 4.8.1 Policies aimed at Improving Work Performance ................................................ 47 4.8.2 Specific Policies for Work Performance ............................................................ 48 4.8.2.1 In-service Training ....................................................................................... 48 4.8.2.1 Recognition and Promotion.......................................................................... 48 4.8.3 Staff Understanding of the Policies .................................................................... 49 4.9 Discussions of Findings ............................................................................................. 49 4.9.1 Motivational Factors and Work Performance ..................................................... 49 4.9.2 Expectations of Nurses in Motivation ................................................................ 52 4.9.3 Motivational Policies .......................................................................................... 52 CHAPTER FIVE ................................................................................................................. 53 SUMMARY, CONCLUSION AND RECOMMENDATIONS ......................................... 53 5.0 Introduction ............................................................................................................... 53 5.1 Summary of the Study ............................................................................................... 53 5.2 Conclusion ................................................................................................................. 55 5.3 Recommendations ..................................................................................................... 55 5.3.1 Recommendation for Practice ............................................................................. 55 5.3.2 Recommendation for Future studies ................................................................... 56 5.4 Limitations of the Study ............................................................................................ 57 REFERENCES .................................................................................................................... 58 APPENDIX: QUESTIONNAIRE ....................................................................................... 61 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table Page Table 3.1: Population and Sample Size............................................................................... 33 Table 4.1: Profile of Research Respondents ....................................................................... 38 Table 4. 2: Summary of Results Showing Frequency of Intrinsic Motivation ................... 40 Table 4.3: Summary of Results showing frequency of Extrinsic Motivation ..................... 41 Table 4.4: Summary of Results showing what Motivates Nurses to Perform .................... 42 Table 4.5: Summary of Regression Analysis of Motivational Factors and Performance ... 44 Table 4.6: Summary of results showing level of influence of Motivational Factors .......... 45 Table 4.7: Summary of Results showing Top Management Involvement in Motivational Issues ................................................................................................................. 45 Table 4.8: Summary of Results showing Existence of Motivational Policies .................... 47 Table 4.9: Summary of Results showing difficulty of understanding motivation policies . 49 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURE(S) Figure Page Figure 2.1: Conceptual Framework..................................................................................... 28 ix University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CHN: Community Health Nurse DDNS: Director of Nursing service E/N: Enrolled Nurses ENS: Enrolled Nurse Superintendents FWSC: Fair Wages and Salary Commission M/O: Midwife Officers, MDGs: Millennium Development Goals N/O: Nursing Officers NLC: National Labour Commission NTC: Nursing Training College PCHN: Principal Community Health Nurses PMO: Principal Midwife PNO: Principal Nursing Officers SCHN: Senior Community Health Nurses SEN: Senior Enrolled Nurses SM: Student Midwife SMO: Officer Senior Midwife Officers SNO: Senior Nursing Officers SSM: Senior Staff Midwife SSN: Senior Staff Nurses x University of Ghana http://ugspace.ug.edu.gh ABSTRACT Work performance is a vital component of every organization that seeks competitive advantage. As such, employee’s motivation as an integral part of the organization is agreed to be of primary concern to both employers and employees. Therefore, the study sought to identify motivational factors influencing work performance of nurses at the Eastern Regional Hospital, Koforidua. With this, two forms of employee motivation (intrinsic and extrinsic) and employee work performance were considered in this study. The objectives were: to identify both intrinsic and extrinsic motivating factors of work performance by nurses at Eastern Regional Hospitals; to find out motivational factors that affect work performance of nurses; to determine the expectations of nurses at the Eastern Regional Hospital; and to identify policies in place with regard to motivation of nurses at the Eastern Regional Hospital. The study employed a cross-sectional explanatory design with a mixed method approach to gather data for analysis through survey questionnaire using 148 respondents. The data was analyzed using frequencies, percentages and simple linear regression. The findings revealed that both intrinsic and extrinsic motivational factors have significant positive influence on nurses’ work performance. Nurses were largely motivated by support from other staffs, recognition, paying attention to individual suggestions, opportunity for promotions, promotion and salary increase. Increase in salaries motivated nurses more than the rest; recognition, motivational talks, promotion and study leave. There is a constantly high expectation of nurses regarding fair treatment, health benefits, allowances, involvement in decision-making, provision of accommodation. Lastly, the study concludes that, even though there are motivational policies, they should be made more active and visible for all employees of the hospital. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTON 1.0 Introduction This Chapter discusses the background to the study, problem statement, objectives and research questions. It further highlights the significance of the study, operational definition of terms and summary and conclusion. 1.1 Background to the Study Motivation is a necessity for organizations to perform better. Motivation may be defined as anything that moves an individual to do or not to do something. In other words, motivation is the process that account for an individual's intensity, direction, and persistence of effort toward attaining a goal. In most cases, motivation stems from a need which must be fulfilled, and this, in turn leads to a specific behaviour (Lambro, Kontodimopoulos & Niakas, 2010). Motivation is not only an inherent factor in individuals, but also a group incentive to act or not to act. Thus, it is an intrinsic process that psychologically directs the behaviour of an individual (Kreitner, 1995; Grafham, Matheson & Bond, 2004) or performance of a task which are naturally enjoyable (Ryan & Deci, 2000). These include responsibility, autonomy, opportunity for advancement and challenging work (Armstrong, 2006). Furthermore, Steers and Spencer (1977) relates motivation to organizational performance. In the healthcare facility, achieving objectives in a population depends to a large extent on the provision of efficient, accessible, viable, and high-quality services by health professionals who technically driven by motivation. According to Lambrou et al. (2010), job performance has often been examined in light of work attitudes such as job satisfaction and organizational commitment. Health workers’ attitudes toward their jobs and their 1 University of Ghana http://ugspace.ug.edu.gh commitment to their employers have interested researchers because of their impact on behavior at work and quality of patient care. In Saudi Arabia, interest has been growing on issues related to performance in health organizations as a reflection of quality improvement (Al-Ahmadi, 2008). Other Scholars have also on the health workers’ contribution of care to patient outcomes as well as performance in the context of motivation. In low- and middle-income countries, optimizing productivity is also considered. Job satisfaction of employees is found to be an important factor affecting productivity and receives considerable interest (Collins, Jones, McDonnell, Read, Jones & Cameron, 2000). The subject of job satisfaction is essential and of key interest to public health practitioners since the organization and that of employees’ health and well-being is embedded in job satisfaction (Adams &Bond, 2000). In recent times, an employee’s willingness to work and stay in an organization depends on the extent to which they are adequately motivated (Adams & Hicks, 2000). Ideally, an individual will better their performance when incentive packages are satisfying and are in line with the capacity to meet the needs. In this regard, while economic factors play a crucial role in the motivation and retention of healthcare workers, including nurses, in the facilities and other work posts (Henderson & Tulloch, 2008), are essential for their loyalty. The workforce in the health sector has specific features that cannot be ignored, and motivation can play a vital role in many of the compelling challenges facing healthcare today. Currently, due to the nature of the economic relationship between the system and those using it (physicians, patients, and hospitals), the task of motivating is complicated and made worse for management of heterogeneous workforce. Most studies suggest that, health organizations are faced with external pressures that cannot be effectively resolved 2 University of Ghana http://ugspace.ug.edu.gh without appropriate adjustments to the workforce; consequently, the development of the workforce is a crucial part of the health policy formulation. Motivation as a healthcare policy is an engine for growth in all facets of healthcare delivery in Ghana (Agyepong et al., 2011). In Africa, health workers face a hierarchy of motivations or disincentives generated by the work they do, the way they are paid, and the organizational and system context in which nurses’ work and the fact that within the healthcare organizations, Nurses constitute the largest human resource element and as such appears to have a great impact on the quality of care and patient outcomes. In order to manage healthcare, these nurses perform numerous and diverse tasks that are not limited to direct contact with patients as well as activities that do not require nurses’ training such as housekeeping; Nursing tasks have however been classified into three categories: direct patient care, indirect patient care, and non-nursing tasks or unrelated tasks (Hobgood, Villani & Quattlebaum, 2005). As a result, incentive packages are designed to encourage providers to provide specific services, ensure cost containment, support staff recruitment and retention; enhance productivity and the quality of services, and allow for effective management (Hongoro & Normand, 2006); Health sector policy makers and managers must recognize the importance of work motivation in reaching sectorial and organizational goals, and must understand the links between the two (Van Lerberghe et al., 2002). In Ghana, there has been a great deal of progress in health outcome indicators. For instance, antenatal and postnatal coverage improved from 42.2% and 33.8% in 2008 to 91.3% and 64.7% in 2011 respectively. Similarly, maternal deliveries percentages also increased 44.2% in 2008 to 52.3% in 2011. Likewise, the number of outpatients visits per capita improved 0.77 in 2008 to 1.07 in 2011 (Ghana Health Service, 2011). Yet, the 2015 targets for health-related Millennium Development Goals (MDGs) was unattainable. This 3 University of Ghana http://ugspace.ug.edu.gh is due to a number of factors, including under staffing in health, inequitable distribution of health sector human resources, de-motivated staff and healthcare infrastructure (Alhassan et al, 2013). For these health’s related MDGs to be achieved, more comprehensive quality improvement interventions, including a health sector human resource (HSHR) approach (Alhassan et al., 2013). Therefore, it is imperative to ascertain the influence of motivation on work performance of nurses. 1.2 Problem Statement According to the WHO (2006), the African continent is currently facing a severe human resource crisis in the health sector thereby affecting the delivery of quality and efficient healthcare services. Friederike (2009) emphasized that, Sub-Saharan Africa has the lowest health worker-to-population ratio in the whole world and this trend is getting worse according to country specific case studies because of internal and external migration. According to Dieleman et al. (2003), the issue of low motivation in the work place is one major contributor to the brain drain of health workers from Africa to other countries and from rural to urban areas within the same country. Also, most researchers focus on studying factors influencing performance in health organizations with emphasis on worker and work environment factors. In healthcare organizations, Nurses constitute the largest human resource element and as such appears to have a great impact on the quality of care and patient outcomes. In order to manage healthcare, nurses perform numerous and diverse tasks that are not limited to direct contact with patients. Nurses also perform activities that do not require nurses’ training such as housekeeping. Nursing tasks have however been classified into three categories: direct patient care, indirect patient care, and non-nursing tasks or tasks unrelated to nursing (Hobgood, Villani & Quattlebaum, 2005). 4 University of Ghana http://ugspace.ug.edu.gh According to DeLucia, Ott and Palmieri (2015), nurses spend more time with patients than any other health care provider, and patient outcomes are affected by nursing care quality, thus, improvements in patient outcomes and safety can be achieved by improving nurse performance. According to White (2000), increased productivity (performance) is as a result of improved job satisfaction. According to Kinicki and William (2008), motivation is subjective hence what motivates one person might not necessarily motivate another. This is because studies show that there are significant differences in terms of what employees want from their work in different countries as well as in different industries or work sectors and at different points in time (Simon & Enz, 1995).This implies that studies on motivation and employee work performance is limited to one country or organization hence cannot be generalized across other countries or organizations. Various motivational factors that influence work performance exist; they include money, recognition, opportunities for career advancement and among others. Some studies on motivation however show that employees are predominantly motivated by money (Fisher, 2005). Other studies on the other hand argue that although money is important, factors such as achievement recognition, responsibility and respect are rather the key factors (Afful-Broni, 2012). Many organizational scholars have shown interest in why some people report being satisfied with their jobs, while others express low levels of job satisfaction. However, much is not known about which factors influence work performance of hospital staff. Factors leading to satisfaction, described as ‘motivators’, were promotional and personal growth opportunities, responsibility, achievement and recognition: these factors are intrinsically rewarding. On the other hand, extrinsic factors also known as “hygiene” factors, leads to job dissatisfaction: examples include pay, physical conditions of the workplace, job security, company policies, supervision and relationship with others (Robbins, 2003). 5 University of Ghana http://ugspace.ug.edu.gh Factors contributing to high levels of work performance at the workplace identify as; supportive colleagues, supportive working conditions, mentally challenging work and equitable rewards (Locke, 1983). Challenging economic conditions in Ghana and high expectation from society have made money a “must have” hence a serious issue in the labour front. It is however not surprising that a great deal of issues that go to the National Labour Commission (NLC) border on salaries and wages (Darteh-Baah & Amoako, 2011). More recent issues that the NLC and the Fair Wages and Salary Commission (FWSC) had to go into negotiations for and settle were doctors, pharmacists as well as nurses in government hospitals, who laid down their tools because of their displeasure with conditions of service, remuneration and unpaid salaries respectively (myjoyonline.com, 2015). Other studies focus on the contribution of nursing care to patient outcomes such as quality of care and patient satisfaction healthcare settings. In Taiwan, staff nurses’ morale is found to be a predictor of patient satisfaction (Yang & Huang, 2005). In Jordan, Mrayyan (2006) examined patient and nurse job satisfactions, and quality of care, Mrayyan concluded that nurses had uncertain level of job satisfaction, while patients reported moderate levels of satisfaction with care, and head nurses reported satisfaction with quality of nursing care. “Based on self-determination theory” (Ryan & Deci, 2000) and earlier studies on nurses’ work motivation, this study focused on both extrinsic and intrinsic motivation, which gave the possibility to investigate not only the level of motivation (from low to high) but also the orientation from which it stemmed (intrinsic or extrinsic) (Ryan & Deci, 2000): individuals are intrinsically motivated to work when they work for their own sake. However, an individual is considered to be externally motivated, when he or she works for instrumental reasons. 6 University of Ghana http://ugspace.ug.edu.gh In Ghana, studies on motivation of healthcare workers are skewed in the quantitative direction. Hence, some of these studies construct regression models to know the relevant motivation factors that induce high work performance among health workers (Agyepong et al., 2004; Beaglehole & Dal Poz, 2004; Kwansah et al., 2012; Lori et al., 2012). For example, Agyepong (2004) studied the relationship between Health worker (internal customer) satisfaction and motivation in the public sector in Ghana. Again, Beaglehole and Dal Poz (2004) observed the challenges and the policy dimension of the public health workforce in Ghana. A study by Kwansah et al. (2012), detailed the policy focus on incentives for rural service among nurses in Ghana. This study adopted cross sectional (mixed method aprroach) approach in order to add on inconclusive studies of motivation and work performance of nurses. The study focused mainly on exploring motivational factors that influence work performance of nurses in Ghana with reference to the Eastern Regional Hospital, Koforidua. 1.3 General Objectives The main objective of the study was to identify motivational factors influencing work performance of nurses in Eastern Regional Hospital, Koforidua. 1.3.1 Specific Objectives The key objectives of the study were to: i. To identify both intrinsic and extrinsic motivating factors of work performance by nurses at Eastern Regional Hospitals. ii. To find out motivational factors that affect work performance of nurses at Eastern Regional Hospitals. iii. To determine the expectations of nurses at Eastern Regional Hospital. 7 University of Ghana http://ugspace.ug.edu.gh iv. To identify policies in place with regards to motivation of nurses at the Eastern Regional Hospital 1.4 Research Questions The following was the main research questions that the study seeks to find. These include; i. What are the intrinsic and extrinsic motivating factors of work performance by nurses in Eastern Regional Hospitals? ii. What are the motivational factors that affect work performance of nurses in Eastern Regional Hospitals? iii. What are the expectations of the nurses in Eastern Regional Hospitals? iv. Are there policies in place with regards to motivation of nurses and how these policies are meeting the nurses’ expectation? 1.5 Relevance of the Study This research will contribute to the body of knowledge on how to improve work performance from nurses’ perspective. The information gained from this survey will also serve as a basis for further research in other facilities, aid in academic research in the field of healthcare as well as inform hospital administrators or policy makers on measures to ensure employee work performance within the workplace environment. The findings, conclusions and recommendations would serve as empirical evidence on which decisions can be made for the benefit of the hospital. More so, completing this study would not only increase the awareness on how important employee job performance is but will create a better insight into the problem of motivation and work performance and therefore suggest appropriate measures to be taken when addressing the challenge in Eastern Regional Hospital, Koforidua. 8 University of Ghana http://ugspace.ug.edu.gh 1.6 Organization of the Study The work comprises of five chapters. The First Chapter elaborates on the background of the research and spells out the problem under study. It also set out the purpose, objectives, research question, significance of the study, scope of the study and Chapter organization. The Second Chapter deals with review of relevant literature, including theoretical foundations of the study relating to the theories on motivation, as well as the empirical evidence on motivation, work performance and the work profile of nurses in Ghana. In this work, the Chapter Three outlines the relevant methodology for the study involving the research approach, study design, scope of the study, study population, study setting, sampling, data collection instrument, sources of data, data analysis and management as well as ethical consideration. The Chapter Four concentrates on data analysis and interpretation of the data as well as discusses the main key findings of the study. The final Chapter (Five) of the study will provide summary, conclusion and recommendation of the study. The recommendation for the findings was directed to inform policy on motivation and to build institutional capacities in the Eastern Regional hospital. 1.7 Definition of Terms i. Motivation: Toode (2015) defines motivation as a “values based, psychobiologically stimulus driven inner urge that activates and guides human behavior in response to self, other, and environment, supporting intrinsic satisfaction and leading to the intentional fulfillment of basic human drives, perceived needs, and desired goals” (Moody & Pesut, 2006, p. 17). ii. Work performance: is defined in this study as the ability to accomplish a work done with satisfaction to the worker. 9 University of Ghana http://ugspace.ug.edu.gh iii. Intrinsic factors: is referred to as internal motivation factors put in place by the hospital to ensure work performance. iv. Extrinsic factors: are defined as the other motivational policies outside the purview of management of premise of the facility that are put in place to ensure effective work performance. 1.8 Chapter Summary and Conclusion This Chapter provides an overview of the background to the problem on motivation. It further discusses the problem statement, key objectives as well as the research questions, justification for this study as well as definition of operational terms is captured in this Chapter. 10 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This Chapter reviews relevant literature on motivation of Nurses and other concepts used for this research. The chapter is categorized into theoretical literature and empirical literature. While the theoretical part explores extensive literature on definitional complexities of motivation and its inherent values, the empirical literature on the other hand reviews the empirical work undertaken by scholars with the goal of establishing relationships and identifying research gaps in those studies. The chapter also includes the theoretical frameworks within which the study was positioned. The researcher adopted the Abraham Harold Maslow’s Theory of Need, Herzberg’s Two-Factor Theory and Vroom’s Expectancy Theory to clearly show the links of the study to the discipline of health service management. 2.1 Concept of Motivation: Definition and Overview The term motivation is explained extensively by scholars in various perspectives (Armstrong, 2001). Hence, there is no absolute definition for motivation. Motivation is defined as an intrinsic process that psychologically directs the behavior of an individual (Kreitner, 1995; Grafham et al., 2004). Similarly, Analoui also illustrated that “motivation is the internal drive necessary to guide people’s actions and behaviors toward achievement of some goals.” (2000, p 324). This driving force comes from the desire to satisfy certain needs and expectations (Mullins, 2005). Motivation, according to Bulkus and Green (2009), is derived from the word “motivate”, which means a move, push or influence to proceed for fulfilling a want. Bartol and Martin (2008) describe motivation as a power that strengthens behavior, gives route to behavior, and triggers the tendency to continue 11 University of Ghana http://ugspace.ug.edu.gh (Farland et al., 2011). This explanation observes that in order to attain assured targets; individuals must be satisfactorily energetic and be clear about their determinations. Chowdhury (2006) also explains motivation as a progression of moving and supporting goal-directed behavior. Hence, it is seen as an internal strength that drives an individual to pull off personal organizational goals (Reena et al., 2009). The concept has variously been defined as an intrinsic process that psychologically directs the behavior of an individual (Kreitner, 1995; Grafham et al., 2004). However, according to Locke and Latham (2004), motivation is not just an internal factor in the individual but also a group incentive as well which influences an individual to act or not to act. Nahavandi and Malekzadeh (1999) also relate motivation to organizational performance: motivation is considered as a drive of stable mind, aspiration, force or interest within the individual that translate into action: this implies that, to motivate someone is to stimulate the person’s interest or cause him to desire to do something. Motivation has also been defined as the characteristic of an individual’s willingness to expend effort and strength towards the pursuit of particular set of behaviors (Tabassi & Bakar, 2009); it could also be viewed as a process by which people choose between alternative forms of behavior in order to achieve goals (Cole 2000); and finally, a way for us to get a better understanding of why people work and why they exhibit certain behaviors in the work place (James, 1999). Jones (1955) provides two main definitions of motivation: Firstly, he defines motivation as a process and this means that it is possible to identify at a point in time during which an individual is motivated or not. Again, there is a subjective reaction, which is present in and underlies the behavior of a motivated individual. Motivation is therefore the force that energizes, directs, maintains and sustains behavior towards a given goal in a work environment. Motivation refers to 12 University of Ghana http://ugspace.ug.edu.gh the means of creating an inner state in the individual that energizes or moves him and directs or channels his behavior towards achieving organizational goals (Garvey, 1997). The individual employee has his needs and problems, which, if satisfied and or resolved, will liberate his energies towards the performance of organizational tasks. At the same time, there are organizational issues that concern the employee, and the resolution of such matters will also enhance the employee’s attitude to his roles in the organization. The needs of the employee could be internal to him, or external within the organization, and the way they are perceived may differ from employee to employee. But however, each employee views his needs; they must be addressed if the employee will contribute his utmost in the workplace. The means of addressing these needs of the employee is what is referred to as motivation. Cole (1997) described motivation as a process in which people choose between alternative forms of behavior in order to achieve personal goals. He added that, the goals sought by individuals can be relatively tangible, such as monetary reward or promotion, or intangible, such as self-esteem or job satisfaction. This reward classified into two- intrinsic and extrinsic rewards. Intrinsic rewards are those that drive from the individual’s own experience; extrinsic rewards are those that are conferred on a person from outside. According to Raimon and Timothy (1991), motivation is a set of forces, originating both within and outside the individual that initiate behavior and determine its forms, direction, intensity and duration. This definition indicates that motivation drives people to behave in certain ways. It recognizes that many forces, internal and external to the individual, may simultaneously play roles. And it sees motivation as not, only initiating behaviors but also guiding it, influencing its strength, and determining whether or not it is sustained. 13 University of Ghana http://ugspace.ug.edu.gh From the definitions above, motivation suggests a set of factors that drive the attention and efforts of individual or group of workers to towards the achievement of some set targets or organizational behavior which are usually tied to organizational short- and long-term objectives. This suggests that individuals are propelled into certain organizational efforts if there are certain incentives, whether monetary or non-monetary are provided are promised. From the organization’s perspective, a main object is to have the employee put up certain traits that that are in the organization’s best interest. Through motivation, an employee can put up positive attitude to work by working hard, being punctual and regular to work and contributing meaningfully to the fulfillment of the organization’s mission. 2.2 Forms of Motivation As claimed by Odoom (2015), in all human organizations, it is motivation that strengthens, directs and sustains human behavior (Huitt, 2003; Ogunrin et al., 2007). It is imperative to state that, these definitions of motivation are influenced by factors that are both intrinsic and extrinsic to the individual. Due to the difficulties in defining intrinsic factors, emphasis is placed on the extrinsic factors, which include the ability of the organization to satisfy its employee’s needs. This section explains both intrinsic and extrinsic forms of motivation. 2.2.1 Intrinsic Motivation Robbins (2003) defines motivation as the desire to work on something that is interesting, challenging, satisfying, exciting or involving. In other words, intrinsic motivation is the motivation to do or act in one’s own interests (Hennessey & Amabile, 2005). In the early 1970s, social and educational psychologists is known to have done studies on intrinsic motivation and explanations concerning intrinsic motivation is also done in the context of Fritz Heider’s attribution theory, Bandura’s (2000) work on self-efficacy, and Deci and 14 University of Ghana http://ugspace.ug.edu.gh Ryan’s (1985), cognitive evaluation theory. According to Deci and Ryan (1985), intrinsic motivation is an innate and natural propensity to engage an individual’s interests and exercise an individual’s skills and capabilities, and also achieve optimal opportunities and challenges. This motivation therefore emanates from internal tendencies and can direct and motivate behavior without the presence of constraints or rewards (Deci & Ryan, 1985). These include responsibility, autonomy, opportunity for advancement and challenging work (Armstrong, 2006). An individual is intrinsically motivated when he or she moves from the challenge or the enjoyment instead of the promise of rewards or avoiding punishment (Deci & Ryan, 1985). Similarly, the cognitive evaluation theory, as well as self-determination theory, specifies factors in social contexts that cause variability in intrinsic motivation (Deci & Ryan, 1985): cognitive evaluation theory argues that those interpersonal events and structures (like feedback, rewards, communication and so on) that lead to feelings of competence during a certain action can increase intrinsic motivation for the specific action since these feelings permit satisfaction of the innate psychological need for competence that is inherent for humans (Deci & Ryan, 1985). In the same vein, the cognitive evaluation theory emphasizes that feeling of competence need to be combined by a sense of autonomy (or internal perceived locus of causality) in order to increase intrinsic motivation (Deci & Ryan, 1985). In the view of Amabile (1993), intrinsic motivators are necessarily bound up with work itself. The intrinsic motivation of having pleasure in a certain activity could propel the individual to spend many days practicing a sport, an instrument, and so on. Therefore, the individual derives satisfaction from such an activity which serves a motivator to work performance. 15 University of Ghana http://ugspace.ug.edu.gh 2.2.2 Extrinsic Motivation Extrinsic motivation is activities performed in order to attain an outcome (Jones & George, 2011). These include salary and wages, praise, bonuses, benefits, coercion and threat of punishment and other tangible rewards. In other words, extrinsic motivation refers to performing an activity with a feeling of being pressured, tension, or anxiety just to make sure that one would achieve the result that one desires (Lindenberg, 2001). Hennessey and Amabile (2005) also define extrinsic motivation as the motivation to do something in order to ensure that an external goal is attain or some external imposed constraint is met. Socio psychological research indicates that, extrinsic rewards can lead to over justification and a subsequent reduction in intrinsic motivation. In one study demonstrating this effect, children who expect to be rewarded with a ribbon and a gold star for drawing pictures spent less time playing with materials for drawing in subsequent observations than children assign to an unexpected reward condition and children who receive no extrinsic reward (Lepper et al., 1973). A number of studies conducted suggest that both intrinsic and extrinsic motivations are important, for instance one study discovered that the most important reward to workers were good benefits and job security which are extrinsic rewards as well as intrinsic rewards such as interesting work, independent work situations and opportunity to learn new skills (Williams, 2007). 2.3 Performance Management Parameters of Performance Drawing strength from Odoom, (2015), Performance management is defined variedly by many scholars. Performance management is an interlocking set of policies which have their focus the enhanced achievement of organizational objectives through concentrated individual performance (Storey & Sisson, 1998). According to the Institute of Personnel Management as quoted by Martinez (2003) defines performance management as “a 16 University of Ghana http://ugspace.ug.edu.gh strategy which relates to every activity of the organization set in the context of its human resources policies, culture, style and communications systems. The nature of strategy depends on the organizational context and can vary from organization to organization”. Performance management is a strategic and integrated approach to delivering sustained success to organization by improving the performance of individual staff (Armstrong & Baron, 1998). It is concerned with broader issues facing an organization and achievement of long terms goals. It is integrated because it aligns all various activities of an organization; individual, teams, management and development of people. On the other hand, Performance measurement offers general information which focuses on decision making purposes for both management and for all levels of employees (Hatry, 2006). Hence, aptitude, the performance measurement system can become the instrument panel: this instrument panel is thereby use as a strategic maneuvering, day to day running of the organization and planning, implementing improvements and changes. (Andersen & Fagerhaug, 2002) Conventional measures of organizational performance are financial and accounting based and this has evolved into sophisticated systems which have several functions: To begin with, the financial measure is used as a tool to control the financial resources of companies in order to support organizational objectives. Also, in terms of financial performance measure acts as a barometer to specify achievements against major organizational objectives. Additionally, these serve as motivators for future achievement as well as provide a window of the past which are influencing factors for future successes. Notwithstanding the merits of the financial and accounting measures in assessing performance, the fact that they were cost based and backward looking provided little motivation (Manzoni & Islam, 2009). This traditional finance-based measure of 17 University of Ghana http://ugspace.ug.edu.gh performance is insufficient and as a result has prompted the search for enhanced metrics to measure performance. 2.3.1 Ways to Measure Work performance Performance appraisal is a systematic review of performance of individual employee on a written basis at regular time interval (Towers, 1996). It involves holding interviews to discuss issues related to performance in the past, present and future. It is usually done on one on one basis usually with immediate manager. In the view of Odoom (2015), performance measurement uses the following indicators of performance: i. Quantity: Hakala (2008) explains quantity as the number of units produced, processed or sold as a good indicator of performance. Thus, by quantity, it refers to the number of patients a nurse is capable of attending to within a given time period. In other words, quantity here implies the ability to provide nursing care and treatment to more patients given a limited period of time. ii. Quality: It is the ability to perform to a desirable outcome: quality of work performance can be measured by the percentage of work output done. iii. Timeliness: it concerns with how fast work is performed and in the service sector, the average customer’s downtime is a good indicator of timeliness. iv. Cost-effectiveness: cost effectiveness is used as a measure of performance only if the employee has some degree of control over costs (Halala, 2008). v. Absenteeism: An employee is obviously not performing when he or she is not at work. Other employees’ performance may be adversely impacted by absences too (Halala, 2008). vi. Adherence to policy: Deviations from policy indicate an employee whose performance goals are not well aligned with those of the company too (Halala, 2008). 18 University of Ghana http://ugspace.ug.edu.gh vii. The author further provides some key instruments and procedures to measure or assess the performance of employees. Some ways through which performance is assessed from the aforementioned indicators includes: a. Managers appraisal: manager appraisal is top-down approach where a manager appraises the employee’s performance and delivers the appraisal to the employee. This type of appraisal does not encourage the employee’s active participation and this is often met with resistance, because the employee has no investment in its development. b. Self-appraisal: The employee appraises his or her own performance, in light of management objectives. Oftentimes, this type of appraisal highlights the differences between what the employee and management believe to be an important performance factor. Thereby provides a mutual feedback for meaningful adjustment of expectations. c. Team appraisal: here, members of a team, who may hold different positions, are asked to appraise each other’s work and work styles. This approach assumes that the team’s objectives and each member’s expected contribution have been clearly defined (Halala, 2008). 2.4 Performance in the Health Sector In the health sector, assessment of healthcare quality service is usually through outcomes of health services which are normally measured in terms of technical aspect rather than interpersonal care. Researchers have emphasized that, taking into consideration the welfare of healthcare employees from the perspective of the workers is a way of improving the client quality in healthcare organizations and a key factor when improving the overall quality of healthcare (Zineldin, 2006). 19 University of Ghana http://ugspace.ug.edu.gh Ideally, the health employees’ performance or quality is defined from patients’ view as a perceived service quality. Thus, consumer's judgment about excellence of the overall health services including every aspect of service such as technical, functional, environmental and administrative, based on perceptions of what is received and what is given (Zeithaml, 1988). In assessing the performance of workers especially, in the service sector the SERVQUAL model is widely used to examine the extent to which health workers perform along certain key indicators. SERVQUAL is an instrument for assessing customer perceptions and expectations of service quality in service organizations. In short, it is based on the gap measures of expectation and perception of patients regarding the quality of healthcare services (Parasuraman et al., 1988). The SERVQUAL instrument consists of 5 dimensions of service quality, including reliability, responsiveness, assurance, empathy and tangibles. i. Reliability: Reliability is the ability to perform the promised service accurately and dependably. It means that the service is accomplished on time without any errors (Parasuraman, 1991). For an example, when a nurse is able to deliver services to their clients on time without any errors, then the nurse’s performance is seen reliable. ii. Responsiveness: Responsiveness is the willingness to assist patients and provide prompt service (Parasuraman, 1991). Keeping customers waiting with no apparent reason can create a low perception of quality. This suggests that nurses ought to treat patients in real time by as far as practicable reducing waiting periods of patients. iii. Assurance: Assurance is the ability to be knowledgeable, to show courtesy and to convey trust and confidence (Parasuraman, 1991). It includes the following 20 University of Ghana http://ugspace.ug.edu.gh features: competence to perform service, politeness and respect for customers and effective communication with the customer. iv. Empathy: Empathy is provision of care and the ability to show compassion towards customers. It includes approachability, sensitivity, and understanding patients’ needs (Parasuraman, 1991). Mostly, nurses have been touted as being inhumane and appear not to show compassion to their patients (Parasurman et al, 1985). Therefore, a key indicator to assess the performance of nurses is the level with which they treat their clients with compassion and empathy they deserve. v. Tangibles: Tangibles deal with the physical appearance of the facility, which satisfied the customers’ interest and desire. The availability of adequate seating and the cleanliness of the washrooms are key constituents of tangibility. 2.4.1 The Effect of Motivation on Performance of Nurses Motivation as a concept has received a lot of argument in contemporary literature; Nurses’ work motivation is deemed to be important for their intent to work (Brewer et al., 2009) and job satisfaction (Blegen, 1993; Freeman & O’Brien-Pallas, 1998; De Loach & Monroe, 2004), and there is a positive relationship between employees’ motivation and organizational performance (Revelle & Anderson, 1995), and detecting factors that increase and decrease the motivation levels of nurses is considered to be a useful means of preventing their dissatisfaction and burnout (Engin & Cam, 2009), or intention to quit nursing (Yildiz et al., 2009). Likewise, a motivated and satisfied nurse is greatly ready to take care of patients and collaborate, hence, provides he or she is able to provide a better healthcare service. Thus, highly motivated nurses have a stronger behavioral, verbal and outcome empowerment than unmotivated nurses (Suominen et al., 2001), whereas low work motivation and job satisfaction, on the contrary, have led to a decrease in both service quality and patients’ 21 University of Ghana http://ugspace.ug.edu.gh intention to return for future care as well as to an increase in the cost of patient care (Yildiz et al., 2009). Improvement of personnel performance forms the core of high- quality healthcare. However, the rate of recent changes has tested the motivation of all healthcare workers who would rather spend their energy on supporting the status quo (Melia, 2006) or on looking for another job (Yildiz et al., 2009). In order to ensure evidence-based continuity, content and quality of practice, several nurse managers and researchers have been looking for a comprehensive model or theory of work motivation for instant use (e.g. Benson & Dundis, 2003; Cubbon, 2000; Moody & Pesut, 2006). There is no doubt that a relationship exists between motivation and workers performance. Several studies suggest that this relationship is a positive one (Yamaguchi, 1999; Douglas & Morris, 2006) and that workers who are not motivated may change their jobs (Pillay, 2009). Researches have revealed that there are different factors that motivate workers (Ogunrin, Ogunrin & Acerola, 2007). Such factors may include teamwork (Maxwell, 2008), financial incentives (Adzei & Atinga, 2012), sense of performance (Tikam, 2011), culture (Yamaguchi, 1999), levels of relations at work (Lopes, 2011), income (materialism); leisure; perquisites; and work per se (Douglas & Morris, 2006). 2.5 Proposed Hypothesis Based on the literature, this study proposed to test the following hypotheses: H1: Extrinsic motivational factors (Promotion, Salary increase, Interpersonal relationship, among others) significantly influence nurses’ performance. H2: Intrinsic motivational factors (Support from other staffs, Recognition, Attention given to your suggestions, Opportunity to advance to senior position) significantly influence nurses’ performance. 22 University of Ghana http://ugspace.ug.edu.gh 2.6 Empirical Evidence 2.6.1 Factors of Motivation In a study to assess work motivation on work performance conducted by Wiley (1997), 200 students at Umea Business School who were assured of becoming the future employees at different industries were asked to rank ten motivation factors according to how they perceive its importance by means of a survey questionnaire. Most important factors were ranked one and the least important ones ranked ten and data analysis was done using Microsoft Excel. The study concludes with the following ranking order by the respondents in the order of the most important to the least important: good wages, full appreciation of work done, job security, promotion, interesting work, and company loyalty to employees, good working conditions, tactful discipline, recognition and sympathetic help with personal problems. The respondents thus ranked ‘good wages’ as the most important factor of motivation. Another study conducted by the Performance enhancement group, the findings from the study indicated that, employees favor daily recognition over bonus or higher pay. Thus, employees who are recognized put in their best efforts in their work (Jeffries, 1997). In support of the results from above study, Hitika and Sirotiakova (2009) noted that workers will work harder if they realize that the work they do is recognized. Similarly, in a research to describe factors affecting health worker motivation and satisfaction in the public sector in Ghana using structured questionnaires, low salary is found to be a de-motivator for over 90% of the respondents (Agyepong, Anafi, Asiamah, Ansah, Ashon & Narh-Dometey, 2004). However, its needs to be emphasized that these factors are not exhaustive for the discussion of motivation as a key drive to positive work performance but the social and cultural foundation of an employee are also key elements in motivating them towards positive work performance. It should be stipulated also that, the above factors are not 23 University of Ghana http://ugspace.ug.edu.gh sacrosanct in all employee motivational studies but they have limited the target population under of employee understudy. Recently in Ghana, researchers have begun to look into the factors that are likely to motivate workers in general and particularly health workers. For instance, a study on Motivation and retention of workers found that financial incentives significantly influence motivation of workers in Ghana (Adzei & Atinga, 2012). It is therefore imperative to hint that any organization, seeking to motivate their workers without adhering to the positivist and de-humanizing management theories of old, then the best approach is to use all of the theories within the contexts they seem best suited for. Since, there is no grand motivation theory which can apply to every person or situation and as such, the only way to truly motivate someone is to simply treat every individual as unique (Hakala, 2008). 2.7 Theoretical Framework 2.7.1 Maslow’s Hierarchy of Needs Theory According to Maslow’s theory (1943), people’s need ranges from a basic need to a high- level need: These needs are inherent in every human being in a hierarchy, namely physiological, safety and security, social, esteem and self-actualization. According to Maslow, failure to satisfy one need will negatively impact the next level need in the hierarchy. Similarly, low level needs take priority over the higher-level needs and as such higher-level needs can be achieve, only after low level needs are satisfied. For him, needs are satisfied in sequence. In addition, this theory argues that people who are struggling to survive are less concerned with needs on the higher levels. The theory though has been widely applied in the organizational setting; it has seen some criticisms from researchers. Maslow’s theory outlines the needs individuals try to satisfy in the work environment which is understandable, but its statement that, these needs must 24 University of Ghana http://ugspace.ug.edu.gh be satisfied in a hierarchical order in fact is difficult to accept. For instance, a person may not have enough money to satisfy his physiological needs (food, water, shelter and clothing) but may have their friends and colleagues at work around them who might help them satisfy their social and esteem needs. The two-factor theory by Herzberg was however used to counter Maslow’s hierarchy of needs theory and therefore also serves as a guide to this study. Abraham Maslow theory of needs is a key theory underpinning motivation of nurses’ base on the intrinsic factors that influences nurses’ work performs. Thus, to some nurse, self- actualization which is at the apex of the theory is their dream hallmark (example, is Florence Nightingale in the profession) and as such sees it as a form of motivation hence, pushes them to effectively work in-order rise from the baseline need of biological and physiological to the level of self-actualization need. 2.7.2 Herzberg’s Two-Factor Theory Frederick Herzberg developed the two factors theory: “motivators” and “hygiene factors”. Herzberg is of the notion that, factors that associate with work dissatisfaction (hygiene factors) varies from those pertaining to work satisfaction (motivators). Hence, there must be some link between performance and reward (intrinsic or extrinsic), in order to motivate employees to perform and improve their satisfaction on the job. Motivators create job satisfactions which include achievement, recognition, autonomy and other intrinsic aspects when an individual is fulfilled. According to Herzberg, the motivator factors pertain to job content such as responsibility, self-esteem, growth and autonomy which correspond to Maslow’s higher-level needs and when satisfied will lead to job satisfaction. Motivators according to Herzberg when present can lead to high motivation, high satisfaction and strong commitment, although their absence may not necessarily lead to dissatisfaction. Granting employees more responsibility and room for creativity in their jobs can influence 25 University of Ghana http://ugspace.ug.edu.gh them to put in more effort and perform better. Herzberg hygiene factors on the other hand create a suitable work environment, though not increase in satisfaction. These factors include: organizational policies and practices, remuneration, benefits, technical supervision, interpersonal relations with supervisor, interpersonal relations with peers and subordinates, salary, job security, personal life and working conditions, which correspond to Maslow’s low level of needs. Improving these factors may decrease job dissatisfaction; however, inadequate hygiene factors may lead to dissatisfaction. These factors need to be seen as priority and tackled first before the motivators can follow. Organizations cannot afford to ignore the hygiene factors as employees will be generally unhappy and thus are more likely to seek after other opportunities while mediocre employees might stay on, and compromise the achievement of organizational goals. The basic assumption of Herzberg two- actor theory indicates that nurse’s productivity at work can be increased through worker satisfaction and that this comes from a variety of factors. For example, jobs should be challenging enough so that nurses utilize their full ability, and workers who are successful should be given more responsibility. This theory serves the basis for effective work performance by nurses Herzberg’s two-factor theory forms the framework within which this study was conducted. The theory explains that although employees have needs which they try to fulfill in the work environment, some of these needs when fulfilled take away dissatisfaction but does not encourage employees to work harder whiles others when fulfilled motivate and leads to satisfaction. Thus, the two-factor theory was used to explain why some employees still find satisfaction with their job despite the presence or absence of certain working conditions (Marfo-Yiadom, 2005). 26 University of Ghana http://ugspace.ug.edu.gh 2.7.3 Vroom’s Expectancy Theory According to Vroom, individuals constantly try to predict the future through the creation of events about the future and how to meet them and before acting, individuals internally calculate the value of the reward and the probability of achieving it. Vroom’s theory of cognitive decision making and behavior stipulates three attributes of motivation: valence, instrumentality, and expectancy. Valence is simply the strength of desire for the perceived outcome and the want of the reward of the end of performing the duty. With regard to Instrumentality, it is the belief that by completing certain steps, the desired outcome will be achieved. Expectancy is the belief that you can actually achieve the desired outcomes. Simply put, Expectancy theory argues that motivation is determined when an individual calculates how much he or she want something, how much of it he or she thinks he or she will get, how likely it is that his or her actions will cause them to get it, and how much others in similar circumstances have received (Ott et al., 2007). With respect to the Vrooms theory, the desire for nurses to be promoted to other higher ranks from the baseline qualification of Principal Nursing Officers which is tied to their salaries stimulates their desire to effectively work and perform the needed professional duty requirements in order to meet the promotional needs. This theory clearly plays well at places where the promotions procedures are clearly adhered by the promotional boards and management. 2.8 Conceptual Framework Intrinsic motivation factors are inherent determinants such as support from other staffs, recognition, Attention given to your suggestions, opportunity to advance to senior position and many more that induces workers to be motivated. Extrinsic motivators in a form of promotion, salary increase, Interpersonal relationship and others are relevant extrinsic 27 University of Ghana http://ugspace.ug.edu.gh factors that ensure motivation. Both intrinsic and extrinsic motivating factors resolve to work performance being high or low depending on how workers are motivated intrinsically and extrinsically. Similarly, performances of nurses are better improved when they are motivated and this motivation can be either intrinsic or extrinsic. Hence, the conceptual framework for the study is bi directional (no direction). Intrinsic Motivation: Support from others, Recognition, Attention to suggestions, Opportunity for Work Motivation Advancement Performance Extrinsic Motivation: Promotion, Salary increase, Interpersonal relationship Figure 2.1: Conceptual Framework Source: Author’s Construct (2019) 2.9 Chapter Summary and Conclusion This chapter reviewed the concept and overview of motivation, relevant theoretical and empirical evidence of the study in-terms of extrinsic and intrinsic motivation. 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE RESEARCH METHODOLOGY 3.0 Introduction This Chapter looks at the methodology used for the study thus, the specific steps used to conduct the study. These includes the research design, study design, study population, study setting, sampling technique and sample size, data collection instrument, data processing and analysis, and ethical considerations . 3.1 Research Design Research design is the procedure and techniques use to answer the research problem explain the pattern the study intended to follow so as to control variance due to independent variables, eliminate or reduce the influence of extraneous variables, minimize error variance and at the same time ensure that the findings can be tested for significance (Sinha & Kurian, 2014; Polonsky, 2009). The design for this research was cross-sectional study (mixed method approach. This is chosen because it allows the researcher to study a target population at a given point in time and thus it is convenient. In order to explore the perspectives, thoughts and explanations of the dynamics of motivation and work performance of nurses, the study adopted a mixed method approach. This design involves the collecting, analyzing and integrating quantitative and qualitative research in order to provide a better understanding of the research problem analyzes of the data, Creswell, et. al (2017) study design. Thus, helped the researcher to have a better insight into motivational factors affecting performance of nurses as well as help in generalization 29 University of Ghana http://ugspace.ug.edu.gh 3.2 Sources of Data This study focused on primary data collection. This data source ensured that the researcher drew practical based conclusions on motivation and work performance to enhance reliability and validity of study findings. Mixed method study was conducted to elicit the views of the nurses on motivation and its influence on work performance. 3.3 Study Setting The Eastern Regional Hospital is established in 1926, which is located at Koforidua. It is a Ghana Health Service secondary level referral facility. There have been two major structural additions to the hospital since its establishment. The first was in 1972 and the second in 1988. Since 2012 up to date, the hospital has seen numerous structural and equipment refurbishments. In addition, a new computerized tomography center has been built and a new digital x-ray and mammography machines have been installed at the radiology department. There has also been a complete refurbishment and installation of new equipment at the neonatal intensive care unit. The hospital is a 372-bed capacity hospital with about 980 staff nominal excluding national service personnel and students on clinical rotations. It’s also a training center for almost all health institutions in Ghana and has bilateral agreement with some institutions in abroad. The main services provided in the hospital are preventive, diagnostic, curative, rehabilitative, outreach and ambulance. The hospital has the following clinical departments: internal medicine, surgery (general surgery, pediatric surgery and genitourinary surgery), obstetrics and gynaecology (including antenatal care clinic, family planning and reproductive health services clinic) ear-nose and throat, eye, out-patient- department, emergency department, dental, herbal medicine, nursing, physiotherapy, laboratory, public health, nutrition, and pharmacy). The administrative and allied 30 University of Ghana http://ugspace.ug.edu.gh departments include: finance, internal audit, general administration, human resource, medical records, information technology, biomedical engineering, procurement, stores and supply, transport, estates and maintenance, catering, environmental health, security, mortuary and Oxygen. The hospital transacts all its financial activities with onsite banking which is managed by Universal Merchant Bank. The administrative set up is as follows: There are five levels in the organizational structure. The hospital is headed by a Medical Director with the following directors/heads who report to him/her; Clinical Director, Head of Nursing, Head of Administration, Head of Pharmacy and Head of Finance. The clinical director oversees work in all the clinical departments and is also the deputy medical director. The head of nursing supervises all the nursing activities in the hospital and have various nursing heads of units and departments who report to her. The head of administration is responsible for the general administration, procurement. The head of pharmacy is responsible for all aspects of medicines in the hospital and oversee work at all the pharmacy outlets in the hospital which are seven in number. These directors together with the medical director form the core management team of the hospital and they meet every Monday morning for management meeting. These heads of units join the core management members on the first Monday of every month for a meeting as House management committee. 3.4 Study Population The study population comprised all nurses in Eastern Regional Hospital from the various departments at the time the study was conducted. The total population of nurses in Eastern Regional Hospital, Koforidua was three hundred and thirty seven (337), comprising of 5 Deputy Director of Nursing service (DDNS) at the facility, 21 Principal Nursing Officers(PNO), 20 Senior Nursing Officers (SNO), who are in-charge of the various wards 31 University of Ghana http://ugspace.ug.edu.gh ranging for OPD to male, female and maternity wards, 27 Nursing Officers(N/O), 59 Senior Staff Nurses (SSN), 45 nursing students from various Nursing Training College who come for clinical sessions at the hospital, 1Principal Midwife Officer (PMO), 8 Senior Midwife Officers (SMO), 7 Midwife Officers (M/O), 24 Senior Staff Midwife (SSM), 31 Student Midwife (SM), 2 Community Health Nurses (CHN), 2 Senior Community Health Nurses(SCHN), 2 Principal Community Health Nurses (PCHN), 56 Enrolled Nurses(E/N), 17 Senior Enrolled Nurses(SEN), 10 Enrolled Nurse Superintendents (ENSupi). 3.5 Sampling Technique The sampling technique used by the study was stratified random sampling. Stratified random sampling is a type of probability sampling in which an entire population is categorized into homogeneous groups (strata) whereby members of the population are randomly chosen from the various strata for the research hence, help reduce cost and improve efficiency. Also, the adopted technique ensured that, members in each group are distinct as a result every member from each group get the equal chance of being selected using simple probability. This sampling procedure was used to select the sample size of one hundred and sixty (160) out of the total Population of three hundred and thirty-seven (337) nurses of Eastern Regional Hospital. 3.5.1 Sampling procedure In estimating sample, it is stated that for a population of 337 nurses, a sample size of 160 nurses is suggested to be a representation of the population. However, because of the relatively large size of the target population, the stratified sampling method was employed to capture majority of the view of the participants. 32 University of Ghana http://ugspace.ug.edu.gh 3.5.2 Sample size determination To determine the sample size, the nurses in Eastern Regional Hospital were arranged in a form of strata with their numbers assigned to them. Table 3.1: Population and Sample Size NURSES NUMBER OF NURSES IN NUMBER OF PEOPLE IN THE STRATA THE SAMPLE DDNS 5 160/337 * 5 =2 PNO 21 160/337 * 21 = 10 SNO 20 160/337 * 20 = 10 N/O 27 160/337 * 27 = 13 SSN 59 160/337* 59 = 28 PMO 1 160/337 * 1 = 0 SMO 8 160/337 * 8 = 4 M/O 7 160/337 * 7 = 3 SSM 24 160/337 * 24 = 11 SM 31 160/337 * 31 = 15 CHN 2 160/337 * 2 = 1 SCHN 2 160/337 * 2 = 1 PCHN 2 160/337 * 2 = 1 E/N 56 160/337 * 56 = 27 SEN 17 160/337 * 17 = 8 ENSupi 10 160/337 * 10 = 5 Nurses from the training 45 160/ 337 * 45 = 21 college Total 160 All the participants’ nurses in the various stratums were there after selected using a simple random sampling to get the sample size of 160. 3.6 Validity and Reliability To validate the questionnaires, a pre-test was done using 10 nurses in the Focos Hospital after which the questionnaires were revised before the main distribution to respondents was done in order to facilitate easy completion. As part of the revision, ‘tenure of work’ was revised to ‘years of work’. Reliability however ensures accuracy, relevance and comprehensiveness (Haroun, 1999). The issue of accuracy was addressed by reducing 33 University of Ghana http://ugspace.ug.edu.gh design fault and sampling bias. Design fault was addressed by piloting and revising the questionnaires, similarly, sampling bias was as well dealt with by obtaining a representative population. To ensure relevance on the other hand, data critical to the objectives of the study were collected as reflected in the research questions. 3.7 Data Collection Method In this section a structured questionnaire with open ended questions (see Appendix A) to gather information from nurses in Eastern Regional Hospital, Koforidua was adopted. Even though structured questionnaire was hard to develop, it is easier to complete and easier to analyze, less expensive, less interferences on the part of the researcher as well as consumes less time as compared to an unstructured questionnaire. Open-ended questions employed by the study on the other hand, allowed respondents to express their views on the subject under discussion. A self-administered questionnaire was used on the assumption that, all the nurses involved in the study are literates. The purpose of the study was communicated to the respondents and instructions were provided as to how questions were to be answered. The questionnaires was divided into five sections: section A typified demographic data such as sex, age, marital status, tenure and educational level of the respondents, section B focused on intrinsic and factors of motivation which the researcher used a five-point Likert scale, and respondents were made to indicate the importance of each factor as it relates to their job, section C on expectations from the profession. In this section the researcher asked respondents to list a number of expectations from their current profession by employing open ended questions, Section D also on Top management interest in motivating nurses and respondents were asked to list a number of them if it applies to them and finally, section E on comments and recommendations regarding motivation of nurses. All these 34 University of Ghana http://ugspace.ug.edu.gh were to be responded to within fifteen minutes. One nurse part of management board was also interviewed using an interview guide. This tool allowed the researcher to identify the perspectives, thoughts and feelings of respondent in order to meet the objectives of the study. The interview lasted for an hour. The main body of the questionnaire was developed using clear and unambiguous wording of questions and terms that were easily understood by respondents. 3.8 Data Processing and Analysis Data collected from the nurses through questionnaires were sorted, organized and coded for easy analysis using the Statistical Package for Social Solutions (SPSS) version 21 as well as Microsoft Excel 2010. This is because, data gathered from the respondents mean nothing until they are analyzed and interpreted and with SPSS, such analysis can be done with easy. The demographic data and the main variables of the study were coded as appeared in the questionnaire (Appendix A) by assigning numbers to the respective items and analysed using frequencies and percentages. The demographic variables were also used in the regression model due to its significant influence during the correlation analysis. The main variables of the study such as motivation and performance of nurses were analysed using simple linear regression. On the part of the qualitative, data collected from the nurses (the open-ended section as well as interviews) was transcribed and analyzed based on the thematic content analysis approach done manually. The thematic analysis involved first transcribing all recorded interview verbatim. The transcribed interviews were then closely read to identify content categories and pattern of responses. The pattern of responses was then developed into 35 University of Ghana http://ugspace.ug.edu.gh themes. Subsequently, these themes served as the pillars around which the analysis was woven. 3.9 Ethical Consideration Before the start of the study, an introductory letter was collected from the department to seek official permission from the hospital management board of the Eastern Regional Hospital, Koforidua in order to facilitate easy access to the hospital. Also, informed consent was sought from participants and the purpose of the study thoroughly explained to them: Participants were informed that, joining the study is voluntary and they are at liberty to opt out at any stage of the study hence, nurses who consented to participate in the study was taken on. Furthermore, nurses who participated in the interviews were assured of reliability, privacy, anonymity and confidentiality so as to avoid the arousal of any related ethical issues. It was made known to the nurse that, the key findings from the interviews was purely for academic purposes. 3.9.1 Chapter Summary and Conclusion This chapter examined the methods used for the study. It outlined mixed method as a suitable research paradigm to study motivational factors influencing the work performance of nurses in Eastern Regional Hospital, Koforidua. The stratified random sampling procedure was used to select respondents for the study. A structured questionnaire with open- ended was used as the main instrument for data collection. The chapter further presented credibility to data analysis and how ethical issues were addressed. 36 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR PRESENTATION AND ANALYSIS OF DATA 4.0 Introduction This section of the study presents the findings based on the data analysis. The presentation of results makes use of tables, frequencies and percentages. The order of presentation in this chapter includes a demographic profile of the respondents, background of data analysis, frequency, percentage and simple regression analyses of the main variables of the study. The results of the study are subsequently discussed. 4.1 Background to the Analysis The study initially chose a sample size of 160 respondents. However, 148 responses were used for the data analysis, giving a response rate of 93%. The 148 respondents used for the study were made up of nurses (senior, middle & lower level nurses) of the Eastern Regional Hospital, Koforidua. After the data had been entered into SPSS (statistical package for social science) software version 21 and screened for missing values, the demographic characteristics of the respondents were analyzed, using frequencies and percentages. The relationships between the independent variables (motivation) and the dependent variable (nurses’ performance) were also tested using frequencies and percentages as well as regression. 4.2 Demographic profile of Respondents The demographic characteristics of respondents were represented in terms of their gender, age, academic qualification, marital status, nurses’ rank and working experience. The frequencies and percentage of these demographic variables are demonstrated in table 4.1. 37 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Profile of Research Respondents Demographic Variable Frequency Percentages (%) 1.Gender Male 61 41.2 Female 87 58.8 2. Age Below-25yrs 14 9.5 26-30yrs 61 41.2 31-35yrs 48 32.4 36-40yrs 15 10.1 41-45yrs 5 3.4 46-50yrs 5 3.4 Above 56yrs 0 0 4. Academic Qualification Secondary 3 2.0 Tertiary 142 95.9 Prefer not to say 3 2.0 5. Marital Status Married 54 36.5 Divorced 3 2.0 Single 91 61.5 6. Nurses’ Rank Staff Nurse 39 26.4 Senior Nurse 52 35.1 Nurse Officer 38 25.7 Principal Officer 12 8.1 General Nurse 1 .7 Supt enrolled nurse 6 4.1 7. Working Experience 0 - 5 yrs. 74 50.0 5 - 10 yrs. 53 35.8 11 - 15 yrs. 16 10.8 16 – 20 yrs. 2 1.4 Above 20yrs 3 2.0 Total 148 100 Source: Fieldwork 2019 From the table 4.1 it is demonstrated that the majority of the respondents were female 83, representing 56% of the total sample size as against males (41%). The ages below 36 years had the highest representation with 123 representing 83%, which indicates that a greater 38 University of Ghana http://ugspace.ug.edu.gh number of the respondents are young adults. The ages of nurses above 35 years constituted 17% (25) of the respondents. Out of the 148 respondents who took part in the study, 142 (96%) of them had completed the tertiary education representing the majority as against the others (4%). It is worth noting that majority (91) of the respondents signifying 62% are singles and 54(37%) of them are married. In terms of their ranks, senior nurses had majority representing 52(35%) of the respondents, followed by staff nurses with 39(26%), nursing officers with 38(26%) and principal nursing officers with 12(8%). The rests of the respondents which constituted the minority held positions like general nurses (7%) and enrolled nurses (4%). The respondents’ work experience spanned from less than five years working experience with 74 (50%) and between five to ten years working experience with 53(36%). Those with more than ten years working experience constituted the minority with 14% of the total population. 4.3 Motivational Factors for work Performance It is noted that a lot of factors motivate employees to performance such career development, job characteristics, recognition, job security, safety measures, performance appraisals among others (Aguenza & Som, 2018; Chowdhury, 2007). These factors are principally grouped into two major motivational forms thus intrinsic and extrinsic forms of motivation (Robbins, 2003; Jones & George, 2011). The analysis in this study therefore grouped the motivational factors into intrinsic and extrinsic forms of motivation. 4.3.1 Intrinsic motivation The results shown in Table 4.2 demonstrate that 36% of the respondents acknowledge (agree) that support from the other staff members is helpful to get them motivated. Equally, 24% of the respondents also indicated (strongly agree) that support from other employees helps in their work performance. While 24% were neutral, 16% disagreed and 39 University of Ghana http://ugspace.ug.edu.gh strongly disagreed that support from other colleagues at work serves as motivation to their work. Table 4. 2: Summary of Results Showing Frequency of Intrinsic Motivation Intrinsic Motivation Strongly Agree Neutral Disagree Strongly Agree (A) (N) (D) Disagree (SA) (SD) 1. Support from the other staff 36(24%) 53(36%) 35(24%) 19(13%) 5(3%) members is helpful to get motivated 2. Management recognizes and 33(22%) 49(33%) 38(26%) 23(16%) 5(3%) acknowledges your work 3. Good safety measures existing in the 43(29%) 54(37%) 17(12%) 27(18%) 7(5%) facility 4. Attention is given to your suggestion 29(20%) 50(34%) 27(18%) 34(23%) 8(5%) 5. Opportunities to advance to senior 62(42%) 36(24%) 28(19%) 11(7%) 11(7%) positions Source: Fieldwork, (2019) Majority (55%) of the respondents ‘strongly agree’ (22%) and ‘agree’ (33%) respectively asserted that management recognizes and acknowledges their work. While 26% of the respondents remain neutral as to whether management recognition and acknowledgement motivates them, 18% of them disregarded this assumption. The existence of good safety measures in the hospital was generally supported to be one of the major factors that motivate nurses at the Eastern Regional Hospital, Koforidua with 66% agreeing and strongly agreeing to this statement. However, 12% remained undecided, 18% and 5% disagreed and strongly disagreed respectively with the fact that good safety measures in the hospital served as motivation for them to improve performance. Even though 54% of the employees at Eastern Regional Hospital, Koforidua ‘strongly agree’ as well as ‘agree’ that attention is given their suggestions, 28% ‘disagree’ and ‘strongly disagree’ with the statement. The results also demonstrate that majority (66%) of the respondents asserted that opportunities to advance to senior positions is a good source of motivation in 40 University of Ghana http://ugspace.ug.edu.gh enhancing their performance. While 19% remained undecided, 12% disagreed to the fact that promotions serve as a good motivational factor. 4.3.2 Extrinsic Motivation From the Table 4.3, extrinsic form of motivation which had five factors was analysed using frequencies and percentages. It was identified that majority of the respondents (64%) perceived that job security is one of the most important extrinsic factors of motivation. Table 4.3: Summary of Results showing frequency of Extrinsic Motivation Extrinsic Motivation Strongly Agree Neutral Disagree Strongly Agree (A) (N) (D) Disagree (SA) (SD) 1. Job security 55(37%) 40(27%) 24(16%) 22(15%) 7(5%) 2. Good relationship with other staff 44(30%) 70(47%) 5(3%) 28(19%) 1(1%) members 3. Effective promotional opportunity 46(31%) 45(30%) 30(20%) 19(13%) 8(5%) 4. Performance appraisal activities are 35(24%) 55(37%) 36(24%) 21(14%) 1(1%) helpful to get motivated 5. Reasonable periodic increases on 50(34%) 29(20%) 28(19%) 33(22%) 8(5%) salary. Source: Fieldwork, (2019) It is demonstrated that 37% of the respondents asserted that job security is a measure of employee motivation and 16% of the respondents were uncertain with 15% ‘disagree’, while 27% also ‘agree’ to the claim that job security is what motivates them. Another factor that measures employee extrinsic motivations is good relationship with other staff members. This factor was ‘strongly agree’ (30%) and ‘agree’ (47%) respectively as an extrinsic motivation. However, 19% of the total respondents ‘disagree’ that good relationship with other staff members. Effective promotional opportunities for nurses serve as strong extrinsic motivation representing 77% and 18% of these respondents disagreed with effective promotional opportunities being a good extrinsic motivation. Majority of the respondents (61%) asserted that performance appraisal activities are helpful in 41 University of Ghana http://ugspace.ug.edu.gh motivating them to perform. Meanwhile, 24% were neutral and 15% disagreed that performance appraisal activities are helpful in motivation. Respondents strongly agree (34%) and agree (20%) that reasonable periodic increase in salary was a good motivator for performance but 22% disagreed with this assertion. Equally, 19% of the respondents remained neutral and 5% strongly disagreed. 4.4 Motivational Factors that Influence Nurses’ Performance The factors that motivated nurses most in the performance of their duties were analysed. The results displayed in Table 4.4 revealed that salary increase (45%) is the highest motivation factor among nurses at Eastern Regional Hospital, Koforidua. Recognition (22%) was the second highest motivation factor in enhancing work performance. Table 4.4: Summary of Results showing what Motivates Nurses to Perform Motivational Factors No of Respondents Percentage (%) Salary Increase 66 45 Recognition 33 22 Motivational Talk 22 15 Promotion 17 12 Leave 10 7 Total 148 100 Source: Fieldwork 2019 Organizing motivational talks (15%) for employees of the hospital influenced the way nurses are motivated to performance their duties. Promotion (12%) is one of the important motivational factors that are asserted to have impact on nurses’ performance. Periodic Leave days for nurses is the least motivational factor that influences work performance. 42 University of Ghana http://ugspace.ug.edu.gh 4.5 Regression Analysis of the Effect of Motivation Factors on Work Performance The second objective sought to find out the effect of the motivational factors on nurses’ work performance. Two hypotheses were developed to be tested in order to achieve the second objective. The first hypothesis stated that extrinsic motivational factors (Promotion, Salary increase, Interpersonal relationship, among others) significantly influence nurses’ performance and the second hypothesis stated that intrinsic motivational factors (Support from other staffs, Recognition, Attention given to your suggestions, Opportunity to advance to senior position) significantly influence nurses’ performance. These were tested using simple linear regression, with motivational factors (intrinsic & extrinsic) being the predictors and nurses work performance being the outcome variable. Work experience and rank of respondents were used as control variables to check if they may have some influence on work employee. Table 4.5 presents the results of this analysis From Table 4.5, the R2 of .524 (52.4%) indicates that the regression model is statistically fit and the p-value of .00 indicates that the model was statistically significant, thus showing a significant influence of the two motivational factors on nurses’ overall work performance (p< 0.05). Furthermore, the standardized beta values of 0.32 and 0.26 indicate that the influence of intrinsic and extrinsic motivation on nurses’ work performance was positive. To add to this, the beta values also indicate that 32% and 26% of the variance among work performance of the respondents can be positively and significantly predicted by motivational activities at Eastern Regional Hospital, Koforidua 43 University of Ghana http://ugspace.ug.edu.gh Table 4.5: Summary of Regression Analysis of Motivational Factors and Performance Model Unstandardised Standardised Coefficients Coefficients B Std. Error Beta t Sig. (p) Constant - - - - - Rank 9.15 3.14 0.429 2.909 0.00 Experience -0.474 1.06 -0.068 -0.447 0.65 Intrinsic 0.238 0.167 0.32 3.142 0.00 Extrinsic 0.229 0.105 0.260 2.173 0.03 Field Data (2019) Note* Dependent Variable: Nurses’ Work Performance, R2 = .524, F= 17.58, df (3, 60), p< 0.05. Therefore, hypotheses one and two were accepted. These finding imply that as nurses are getting engaged with motivational factors at work, it can increase their levels of overall work performance at work as well as the hospital as a whole. 4.6 Other Incentives and Benefits that Influence Work performance Respondents were asked to indicate whether incentives and other forms of benefits really influence their performance as demonstrated in the Table 4.6. Majority of the respondents (70%) confirmed that they were influenced by the motivational activities existing in the hospital. The other 30% supported the idea that the existing motivational factors do not really influence their performance. 44 University of Ghana http://ugspace.ug.edu.gh Table 4.6: Summary of results showing level of influence of Motivational Factors Level of Influence No of Respondents Percentage (%) Influence 104 70 Do not Influence 24 16 No opinion 20 14 Total 148 100 Source: Fieldwork 2019 4.7 Top management Involvement in Decision Making The respondents 46% indicated that occasionally top management involves them in decision making and 33% consistently asserted that top management involvement of nurses in decision making was inconsistent and therefore not available. About 21% of the respondents only agree that top management involved nurses in decision making. Table 4.7: Summary of Results showing Top Management Involvement in Motivational Issues Top Management Involvement No of Respondents Percentage (%) Yes 31 21 No 49 33 Occasionally 68 46 Total 148 100 Source: Fieldwork 2019 4.7.1 Expectations from Current Job The third objective of the study was to determine the expectations of nurses in the Eastern Regional Hospital, Koforidua. In order to achieve this objective, the expectations of the respondents were captured in open-ended questions. These open-ended answers gave the respondents the opportunity to deeply express themselves in writing. Various themes were 45 University of Ghana http://ugspace.ug.edu.gh developed after carefully going through the individual’s responses. The result revealed that nurses expect fair treatment for all categories of nurses, recognition, job security, promotion, salary increase, motivation from management, granting of study leave, health benefits packages for staff and family, car maintenance allowances, involvement in decision making, provision of accommodation, flexible working hours, among others. Major themes were: 4.7.1.1 Compensation and Reward Packages Based on the analysis most respondents expressed that compensation and reward packages at their workplace were key among their expectations for management. For instance, one respondent indicated that: My expectations as nurse concerning motivation are salary increment, effective numerations and pension, effective promotional opportunities, effective in-service training and opportunities for further studies (Respondent # 11). Another respondent noted that: Health benefit packages for staff and family, car maintenance allowances, staff welfare and job security (Respondent # 8) 4.7.1.2 Good Work Conditions Another key theme that emerged in the analysis of health workers expectations was good working conditions. Yet other respondents concluded that: Safe working conditions, flexible working hours that allow time for staff to spend with family, having competent co-workers, pay rise, supportive supervision (Respondent # 22) To improve on quality of care for clients, to improve on the security of patient and staff in the hospital, to improve on staff-patient ratio and to improve on the computerized system in use (Respondent # 45). 46 University of Ghana http://ugspace.ug.edu.gh 4.8 Top management interest in Motivating Workers The top management interest in motivating nurses at Eastern Regional Hospital, Koforidua of the eastern region was analysed regarding the motivational policies geared towards improving the work performance of nurses. 4.8.1 Policies aimed at Improving Work Performance The fourth objective of the study sought to identify policies in place with regards to motivation of nurses and examine whether or not the policies are meeting the nurses’ expectation. In order to achieve this objective, a confirmation analysis was done verify whether motivational policies existed at the hospital and whether respondents could enumerate some of the existing motivational polices at the Eastern Regional Hospital, Koforidua. From the Table 4.7, 28% of the respondents attested that there are no existing motivational policies to enhance nurses work performance. Equally, 24% of the respondents had no idea whether there are existing motivational policies in the hospital. Yet, 20% of the respondents were unsure if motivational policies exist. However, 27% of the respondents indicated that they are aware of existing motivational policies. Table 4.8: Summary of Results showing Existence of Motivational Policies Motivational Policies No of Respondents Percentage (%) Yes 40 27 No 42 28 Maybe 30 20 No idea 36 24 Total 148 100 Source: Fieldwork 2019 47 University of Ghana http://ugspace.ug.edu.gh 4.8.2 Specific Policies for Work Performance From the 27% (Table 4.7) of the respondents who asserted that there are motivational policies in place at the Eastern Regional Hospital, Koforidua, key motivational policies were highlighted including in-service training organized for nurses, annual awards, workshops or presentations, professional development, promotions and study leaves for workers for their academic enhancement. These policies as enumerated by the respondents help improve motivations thus individual work performance. Major themes that emerged were: 4.8.2.1 In-service Training One major theme that emerged in the analysis was in-service training for nurses. Most of them agreed that there is an existing policy on the training and development of the workers and in-service training was one of the ways through health workers could be trained and developed. Examples of responses included: I personally think there are existing policies regarding motivation in this hospital. There is a policy on how nurses go on study leave and even normal leave. You would have to serve at least three years to be able to qualify for study with leave pay in order to enhance your job knowledge, skills and abilities. Workshops and presentations are organized from time to time in the hospital… (Respondent #87). 4.8.2.1 Recognition and Promotion Another major theme was recognition and promotion. Most health workers expressed the policy of recognizing and promoting hardworking workers periodically was existing and active. This policy helped in retention of workers as it motivates them to put out their best at work. One respondent contributed that: For me, there are motivational policies in the hospital like promotions, recognition of hard work of some individuals with distinct contributions and there are also annual awards programmes being held in the hospital... (Respondent # 16). 48 University of Ghana http://ugspace.ug.edu.gh 4.8.3 Staff Understanding of the Policies Respondents were asked to describe how difficult these policies were. The results in Table 4.9 indicated that 64% representing majority of the respondents asserted that the motivational policies are not difficult to understand. However, while 16% agreed that these policies were difficult to understand, 21% of the respondents were unsure. Table 4.9: Summary of Results showing difficulty of understanding motivation policies Level of difficulties No of Respondents Percentage (%) Yes 23 16 No 94 64 May be 31 21 Total 148 100 Source: Fieldwork 2019 From the results, the effectiveness of the motivational policies is mostly effective in its effort in enhancing employee work performance. However, it was noted that these policies are usually carried out on personal grounds rather than on merits. 4.9 Discussions of Findings The discussions were made based on the study variables and objectives of the study. 4.9.1 Motivational Factors and Work Performance The analysis of the results revealed that nurses’ motivational factors are categories into two forms of motivation such as intrinsic and extrinsic motivation. In terms of intrinsic motivation, majority of the respondents as against minority asserted that support from colleagues, management recognition, safety measures, paying attention to individual worker’s suggestion and opportunities to advance to higher positions, are the main factors that motivate nurses in the discharge of their duties. These assertions support the findings 49 University of Ghana http://ugspace.ug.edu.gh of Deci and Ryan (1985), Amabile (1993) and Armstrong (2006). For instance, this study’s findings supported that assertion that intrinsic motivation is an innate and natural propensity to engage an individual’s interests and exercise an individual’s skills and capabilities, and also achieve optimal opportunities and challenges. This motivation therefore emanates from internal tendencies and can direct and motivate behavior without the presence of constraints or rewards (Deci & Ryan, 1985). These include responsibility, autonomy, recognition, support form colleagues, opportunity for advancement and challenging works (Armstrong, 2006). The findings showed that extrinsic form of motivation also captured the interest of nurses by enhancing their performance. Motivational factors like job security, promotions, performance appraisals activities, increase in salaries and good relationship with colleagues affected nurses at Eastern Regional Hospital, Koforidua perform at duty posts. These findings confirm the view of Jones and George (2011) that extrinsic motivation included salary and wages, praise, bonuses, benefits, coercion and threat of punishment and other tangible rewards. These findings also support the assertions of Williams (2007) that the most important reward to workers was good benefits and job security which are extrinsic rewards as well as intrinsic rewards such as interesting work, independent work situations and opportunity to learn new skills. The findings also revealed that increase in salaries is the greatest enhancer of work performance among nurses at Eastern Regional Hospital, Koforidua. This was followed by recognition, motivational talks, promotion and study leave in the order of dominance. This means that nurses at the Eastern Regional Hospital, Koforidua are generally motivated by increase in salaries. This goes a long way to reinforce that money remains the highest extrinsic motivator among employees. The findings confirm Wiley’s (1997) ranking of motivational factors in the order of the most important to the least important: good wages, 50 University of Ghana http://ugspace.ug.edu.gh full appreciation of work done, job security, promotion, interesting work, and company loyalty to employees, good working conditions, tactful discipline, recognition and sympathetic help with personal problems. The respondents thus ranked ‘good wages’ as the most important factor of motivation. It is also observed that these findings support that several factors improve work performance including financial incentives (Adzei & Atinga, 2012), teamwork (Maxwell, 2008), recognition (Tikam, 2011), levels of relations at work (Lopes, 2011), income (materialism); leisure; perquisites; and work per se (Douglas & Morris, 2006). The findings also revealed that both intrinsic and extrinsic factors have significant positive effect on nurse’s work performance. This means that intrinsic factors such as support from other staffs, recognition, attention given to your suggestions, opportunity to advance to senior position have positive influence on nurses’ work performance. This confirms the assertion that motivated and satisfied nurses are greatly ready to take care of patients and collaborate, hence, provides better healthcare services. Thus, highly motivated nurses have a stronger behavioral, verbal and outcome empowerment than unmotivated nurses (Suominen et al., 2001). It is noted from the analysis that extrinsic motivation such as promotion, salary increase, inter-personal relationship, among others significantly influence nurses’ work performance. This finding supports the view that there is a positive relationship between motivation and workers’ performance (Yamaguchi, 1999; Douglas & Morris, 2006). The finding also established the claim by Yildiz et al. (2009) that improvement of personnel performance forms the core of high-quality healthcare. 51 University of Ghana http://ugspace.ug.edu.gh 4.9.2 Expectations of Nurses in Motivation The expectation of nurses revealed that nurses expect fair treatment for categories of nurses, recognition, job security, promotion, salary increase, motivation from management, granting of study leave, health benefits packages for staff and family, car maintenance allowances, involvement in decision making, provision of accommodation, flexible working hours, among others. This means that employees desire to be motivated by most of these factors. It is noted their expectations and that factors mentioned in the intrinsic and extrinsic motivational factors do not differ. This supports the idea that employee motivation is an important element of human resource management practices (Armstrong, 2013). The findings confirmed the assertion of Hitika and Sirotiakova (2009) that workers will work harder if they realize that the work they do is recognized, rewarded diligently and they are safe and secured in their jobs. This also connotes Herzberg’s two factors theory (Hygiene and the Motivators) on employee motivation. 4.9.3 Motivational Policies For motivational factors to yield good results in any organization, it is better for that organization to formulate policies governing how employees are motivated or otherwise (Armstrong, 2013). The results acknowledged that there are policies regarding employee motivation at Eastern Regional Hospital, Koforidua, even though others also expressed that they have no idea about the existence of policy documents regarding the motivation of nurses to enhance performance. The findings revealed that in-service training organized for nurses, annual awards, workshops or presentations, professional development, promotions and study leaves for workers for their academic enhancement are among some of the policies at Eastern Regional Hospital, Koforidua. These employees also asserted that these policies are not difficult to understand. Therefore, compliance to existing policies regarding motivational policies was good and healthy. 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.0 Introduction This section of the study presents a summary of the study and provides an adequate conclusion as well as appropriate recommendations for practice and research. 5.1 Summary of the Study The purpose of the study was to identify motivational factors influencing work performance of nurses in Eastern Regional Hospital, Koforidua. With this, two forms of employee motivation (intrinsic and extrinsic) and employee work performance were considered in this study at the Koforidua hospital in the Eastern Region of Ghana. The objectives were: to identify both intrinsic and extrinsic motivating factors of work performance by nurses at Eastern Regional Hospitals; to find out motivational factors that affect work performance of nurses; to determine the expectations of nurses at the Eastern Regional Hospital; and to identify policies in place with regards to motivation of nurses and examine whether or not the policies are meeting the nurses’ expectations at the Eastern Regional Hospital. The study employed a cross-sectional explanatory design with a mixed method approach to gather data for analysis through survey questionnaire using 148 respondents. With regards to the demographic details, females largely dominated the sample respondents, majority of the respondents were in their youthful and middle ages, majority of the respondents had tertiary education with majority being staff and senior nurses and lastly, majority of the respondents had worked for less than ten years in their various units. 53 University of Ghana http://ugspace.ug.edu.gh With respect to the objectives of the study, the first objective which sought to identify both intrinsic and extrinsic motivating factors of work performance by nurses in Eastern Regional Hospitals was achieved. The finding indicated that nurses were largely motivated by support from other staffs, recognition, attention to individual suggestions, opportunity for promotions, promotion, salary increase, inter-personal relationship, among others. The second objective which also sought to find out motivational factors that affect work performance of nurses in Eastern Regional Hospitals found that increase in salaries is the greatest enhancer of work performance among nurses, followed by recognition, motivational talks, promotion and study leave. The findings also revealed that both intrinsic and extrinsic motivational factors have significant positive influence on nurses’ work performance. The third objective which sought to determine the expectations of nurses in Eastern Regional Hospital found that nurses expect fair treatment for categories of nurses, recognition, job security, promotion, salary increase, granting of study leave, health benefits packages for staff and family, car maintenance allowances, involvement in decision making, provision of accommodation, flexible working hours, among others. The four objectives which sought to identify policies in place with regards to motivation of nurses at the Eastern Regional Hospital also found that there are policies regarding employee motivation, even though others also expressed no idea such existing policy documents regarding the motivation of nurses to enhance performance. Some of the policies indicated were in-service training organized for nurses, annual awards, workshops or presentations, professional development, promotions and study leaves for workers for their academic enhancement. 54 University of Ghana http://ugspace.ug.edu.gh 5.2 Conclusion Worker performance is a vital component of every organisation that seeks competitive advantage. As such, employee’s motivation as an integral part of the organization is agreed to be of primary concern to both employers and employees. The factors that motivate employees to performance are important for increasing the work output of employees through emotional attachments with and to the organization respectively. This study has demonstrated that both intrinsic and extrinsic motivational factors have engendering nurses’ work performance at the Eastern Regional Hospital. The expectations of nurses are high and positive regarding motivational factors. There is mixed (high and low) recognition of the existing motivational policies in place. It can thus be concluded that nurses in the hospital motivated by both intrinsic and extrinsic factors with increase in salaries being the highest motivational factor. It is also concluded that apart from the intrinsic and extrinsic motivational factors mentioned, there is a constantly high expectation of nurses regarding fair treatment, health benefits, allowances, involvement in decision-making, provision of accommodation. Lastly, the study concludes that, even though there are motivational policies, there should be made more active and visible for all employees of the hospital. 5.3 Recommendations The recommendations of this study are appropriately done based on the findings through the recommendation for practice and recommendation for future studies below: 5.3.1 Recommendation for Practice First and foremost, the findings indicated that nurses are motivated to enhance performance through intrinsic and extrinsic motivations. These findings have great implications for the hospital and other hospitals as well as the Ghana Health Service since 55 University of Ghana http://ugspace.ug.edu.gh good and appropriate motivational factors enhance better work performance which leads to better organizational performance and improvement in human life. The hospital must endeavor to review its motivational factors and activities or programmes and implement better motivational schemes that would lead to higher performance of nurses. The hospital could improve not only more direct (extrinsic) forms of motivation but also indirect (intrinsic) forms of motivation such as support from other staffs, recognition, attention to individual suggestions, opportunity for promotions, promotion, salary increase, inter- personal relationship, among others. This could go a long way to boost their performance and result in greater output to the hospital and Ghana Health Service in general. Also, the hospital must endeavor to ascertain and sustain the expectations of nurses by introducing more activities like fair treatment, health benefits, allowances, involvement in decision-making, provision of accommodation among others since these factors will largely influence their performance at work. What motivates nurses is dynamic and thus, the management of the hospital could research within the units or departments to find out what employees expect in order to engender greater performance. The management of the hospital must also endeavor to develop and maintain major policy documents on the motivation of employees. This will help the hospital to structure its motivational activities for employees. This will involve organizing organizational and employee need analysis to be able to identify the key motivational factors that motivates nurses occasionally. This will help management to update its policy documents regarding the types of motivational factors that should have priorities. 5.3.2 Recommendation for Future studies Seeing that motivation has several forms and factors, future studies could replicate this study to examine the influence of these factors on employee’s performance. 56 University of Ghana http://ugspace.ug.edu.gh The study was done in a single hospital, thus future studies could extend this study to other hospitals and even other organisations. Eastern Regional hospital is a government hospital, future studies could examine the difference between government and private hospitals regarding the influence of motivation on work performance. Furthermore, the study employed a mixed method but did not focus much on the qualitative aspect due to time constraint, thus future studies examine deeply motivational factors through the use of in-depth interviews. 5.4 Limitations of the Study The study was limited by time as such the data collection was limited to only 148 respondents. The sample size could have been larger enough for generalization. Again, the generalizability of the findings to other institutions even to other hospitals may be limited since the study concentrated on a single hospital with a sample that is not representative of the entire Ghanaian organisations. These notwithstanding, the findings of this study are credible and the information provided is very useful. 57 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adams, A., & Bond, S. (2000). Hospital nurses’ job satisfaction: Individual and organizational characteristics, Journal of Advanced Nursing, 33, 536-543. Adams, O., & Hicks, V. 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International journal of health care quality assurance, 19(1), 60-92. 60 University of Ghana http://ugspace.ug.edu.gh APPENDIX: QUESTIONNAIRE UNIVERSITY OF GHANA BUSINESS SCHOOL DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT To Whom It May Concern Dear Sir / Madam My name is MIRIAM ALORZUKEY, a candidate of University of Ghana Business School in Department of Public Administration and Health Services Management. As part of the requirement of the Masters of Business Administration in Health Services Management Degree, I am expected to undertake a research study. I kindly ask for your participation in this study that examines Motivational Factors Influencing Work Performance of Nurses in Eastern Regional Hospital, Koforidua. As a Nurse in Eastern Regional Hospital, your concern and contribution may form as guide in shaping the facility’s policies regarding motivation of Nurses. The attached questionnaire will take less than fifteen minutes to complete. Kindly respond to all the questions. The research result will only be used for academic purpose and treated with utmost confidentiality. However, participation in this study is voluntary and may withdraw at any point necessary. Only summary result will be made public. Your Co-operation will be appreciated Yours Sincerely, MIRIAM ALORZUKEY (Tel: 0542642236) (E-mail : alorzukeymiriam@gmail.com) 61 University of Ghana http://ugspace.ug.edu.gh SECTION A: DEMOGRAPHIC DATA In this section, kindly provide the information below by ticking 1. Gender Male [ ] Female [ ] 2. Age Below 25 years [ ] 26 - 30 years [ ] 31 – 35 years [ ] 36 – 40 years [ ] 41 – 45 years [ ] 46 – 50 years [ ] Above 50 years [ ] 3. Marital Status Married [ ] Divorced [ ] Single [ ] Widowed [ ] 4. Educational Background Primary [ ] Secondary [ ] Tertiary [ ] 62 University of Ghana http://ugspace.ug.edu.gh Vocational [ ] Prefer not to say [ ] Other, specify ………………………………………………………………………………. 5. What is your rank as a nurse? ………………………………………………………………………………………………. 6. How long have you worked as a nurse in this hospital? ………………………………………………………………………………………………. SECTION B: INTRINSIC AND EXTRINSIC FACTORS OF MOTIVATION Please rate the below on the following rating: 1. Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagree Intrinsic and Extrinsic Factors of Motivation 1 2 3 4 5 Job Security Good relationship with other staff members Effective promotional opportunities Performance appraisal activities are helpful to get motivated Reasonable periodical increased in salary Support from the other staff members is helpful to get motivated Management recognizes and acknowledges your work Good safety measures existing in the facility 63 University of Ghana http://ugspace.ug.edu.gh Attention is given to your suggestion Opportunities to advance to senior positions 7. Which of the following motivates you most? Salary increase [ ] Promotion [ ] Leave [ ] Recognition [ ] Motivational talk [ ] 8. Do you think that incentives and other benefit influences your performance? Influence [ ] Does not [ ] No opinion [ ] 9. Does Top Management involve you in decision making which are connected to your department? Yes [ ] No [ ] Occasionally [ ] 64 University of Ghana http://ugspace.ug.edu.gh SECTION C: EXPECTIONS FROM YOUR CURRENT PROFESSION Kindly list as many as possible in the paragraph below 10. What are your expectations from your current job? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… SECTION D: TOP MANAGEMENT INTEREST IN MOTIVATING NURSES Kindly tick and indicate by listing when necessary 11. Are there policies aimed at improving the work performance of nurses aside the ones above Yes [ ] No [ ] Maybe [ ] No idea [ ] 12. Specify by listing them if, there are policies like that ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 13. Does these policies difficult to understand Yes [ ] No [ ] Maybe [ ] 65 University of Ghana http://ugspace.ug.edu.gh Other, specify …………………………………………………………………………… 14. How effective are these policies? ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………. ……………………………………………………………………………………………… ……………………………………………………………………………………………… SECTION E: COMMENTS AND RECOMMENDATIONS REGARDING MOTIVATION OF NURSES TO ENHANCE THEIR PERFORMANCE Kindly list as many as possible 15. Are there areas regarding your job that needs crucial attentions? Yes [ ] No [ ] 16. If Yes please specify ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 17. What other recommendations do you think will help improves the performance of Nurses ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Thank you 66