Is motivation at work for nurses in two NHS hospitals dependant on job satisfaction or financial incentives?
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The National Health Service was described in a BBC News article in 2000 (BBC, 2000) as an organization in crisis as it analyzed various factors impacting the agency. The report indicated the new government mandate titled, “The NHS Plan: A Plan for Investment: A Plan for Reform” (NHS, 2000) consisting of billions committed to improving the services across a wide breathe of areas which included the following concerns as brought forth via consultation with NHS staff members and the public (NHS, 2000). The consultation consisted of interviews and surveys with 58,000 staff members and 152,000 members of the public, with the following ten areas the top concerns the public and staff members voiced:
Table 1 – Top Ten Concerns Voiced by the Public and NHS Staff Members
(NHS, 2000):
Public
Staff Members
1
More staff members with higher pay
scales, the foregoing includes increased
doctors, nurses, scientists and
therapists,
More staff, with the top concern
mentioned as increases in this area and
higher pay,
2
a reduction in waiting times for
appointments as well as on trolleys and
casualty,
additional training along with an
improvement in management shills
across all staffing levels,
3
an improvement in the ways
or working with “bring back the matron”
(NHS, 2000) mentioned as one aspect
of the foregoing
an increase in what was termed as
‘jointed-up’ working with social
services at the community as well
as primary care levels,
4
focusing care that is centered on the
patients with action to be taken on
operations that have been canceled as well
as providing more convenient services,
reduced bureaucracy, consisting of
less administration along with an
improvement in funding systems,
5
a higher quality of care provided with
cancer and heart disease mentioned
prominently,
more action and information on
prevention to reduce the causes
of ill health,
6
better medical facilities
consisting of cleaner locations with a
better quality of food and attention
to getting the basics correct,
improved working conditions along
with increased aids for recruitment
as well as staff retention, and more
flexibility in working patterns,
7
an improvement in facilities for NHS
staff, with rewards and recognition for
the work done by staff members,
a reduction in waiting times,
8
an improvement in location services
along with improvements in local
hospitals as well as surgical facilities,
patient centered care, with staff
frustration concerning the system being
too focused on itself and its needs
without meeting individual patient
needs
9
an end to the postcode lottery and
the assurance of higher quality
in all locales,
Increased performance as well as
accountability systems to reduce
variances in care in different locales
10
increased prevention along with better
assistance on information and help on
healthy living
An increase in autonomy for local
services to provide them with more
control over their organization and
a reduction in control from
Whitehall
The preceding indicates the similarity of views and concerns between the public and NHS staff in 2000 at the inception of the government’s “The NHS Plan: A Plan for Investment: A Plan for Reform” (NHS, 2000). In June of 2004 the Department of Health reported on the “NHS Improvement Plan” (Department of Health, 2004) which detailed the progress made in the NHS since the year 2000. The ‘Forward’ to this document by Prime Minister Tony Blair summarized the achievements and status of the NHS and the following calls attention to those areas as indicated in Table 1 – Top Ten Concerns Voiced by the Public and NHS Staff Members:
Under the ‘Plan’ thousands of additional doctors and nurses, representing a 22% rise in doctors, 21% increase in nurses and a 27% rise in scientific staff,
new incentives for staff and pay contracts have been implemented,
incentives have been created to reward staff for service commitments and improvements,
dozens of new hospital facilities have been opened under the ‘Plan’,
there has been a reduction in waiting times, from 18 months to under nine months,
outpatient appointments have been reduced from 26 weeks to 17 weeks,
cancer and heart disease death rates have been reduced,
new services such as NHS Direct and Walk-in Centres have been implemented,
patient care has been improved with faster diagnosis and treatment times
clinical governance has aided in aiding in evaluation and overall service improvement as implemented under “The NHS Plan: A Plan for Investment: A Plan for Reform” (NHS, 2000)
The preceding represent a summary of the status report on the improvements in the NHS since the adoption of “The NHS Plan: A Plan for Investment: A Plan for Reform” (NHS, 2000). The foregoing information is endemic to the examination of whether motivation at work for nurses is dependent upon job satisfaction or financial incentives as the NHS is a countrywide operation and the overall system impacts upon each hospital and staff member even in the best of situations. Thus, the overall climate and atmosphere of the NHS is an important factor in understanding the context of this examination. The underlying facts are that in terms of health care expenditures and other areas the United Kingdom spends just $1,813 per resident as compared to $2,387 for France, $2,780 for Germany, $2,580 for Canada and $4,500 for the United States (OECD, 2003). And the foregoing is further exacerbated by the fact that the United Kingdom has just 2 physicians for each 1,000 in population as compared against 2.8 in the United States and 3.3 in Germany and France (Stevens, 2004, pp. 37-44). And while the shortfall of physicians represents a major NHS problem, it is the nurses who see to the multitude of tasks and daily patient care which makes the hospitals run and the shortage of these professionals is a critical component in better health care.
A BBC News article in 1999 pointed out that some of the reasons for the shortage of nurses in the NHS are due to poor pay as well as conditions that have affected retention as well as recruitment (BBC News, 1999). The sub-standard pay scale was illustrated through a survey that found that one fifth of all health workers had taken on a second job to enable them to meet expenses, and that one third worked an average of two weeks per year without pay as a result of extra overtime work (BBC News, 1999). The article (BBC News, 1999) added that pay was not the only factor in the nursing shortage problem, the nurses mentioned conditions and a lack of job satisfaction due to the long working hours, heavy pressure, under staffing and lack of recognition. This document shall examine the crisis confronting the NHS with respect to nurses from the standpoint of whether the motivational factor for these professionals is dependant upon job satisfaction or financial incentives. This examination shall utilize secondary survey sources as well as a primary survey to equate these aspects along with theoretical research and opinions.
Chapter 2 – Literature Review
In examining the question of whether motivation for nurses in the NHS is dependant upon job satisfaction or financial incentives, an understanding of various motivational theories is critical to this review. A central subject in the study of psychology, motivation was equated by Sigmund Freud who thought that a good part of the behavior of human beings was based upon unconscious motives and or irrational instinctive urges (Encyclopedia Britannica, 2006). Behavioral psychologists, however, stress that the importance of external goals plays a huge role in prompting action, and humanistic psychologists believe that it lies in felt needs (Encyclopedia Britannica, 2006). A major study conducted by the Kings Fund (2002) pointed out that the government’s commitment to add an additional ?9.4 billion in funding to improve NHS services to bring the agency into closer proximity with the spending of other European countries, as well as the additional of more nurses, therapists and consultants in and of itself was not enough. The Report stressed that the problems of staff retention and recruitment have their roots in good morale and motivation, and that the foregoing is an essential component in order to have a healthy workforce as well as to aid in the attraction as well as retention of nurses (Kings Fund, 2002). The Report went on to state that the NHS needs to have a better understanding of both the positive and negative factors acting upon motivation and morale, as these aspects need to be addressed as part of improving the overall state of service delivery in the NHS (Kings Fund, 2002).
The preceding implication has been borne out in an article by Margaret Callaghan (2003, pp. 82-89) who conducted a study on morale amongst fifty-eight nurses, 30 were females and 28 were male) regarding morale and career concerns. The study found that morale was extremely low among the respondents with a large number of the group surveyed seriously thinking of leaving the profession. More importantly, the feelings among the surveyed group were so strong regarding the negative aspects of nursing in the NHS that they indicated that the majority of those surveyed indicated they would discourage others from entering the profession, citing disillusionment, limited advancement opportunities, job insecurity, limited resources and the lack of support for furthered education, which equate to motivational issues, as well as low pay (Callaghan, 2003, pp. 82-89). Interestingly, the findings of the study indicated that recent increases in the pay scale had helped to improve staff morale however; this development only partly offset other factors (Callaghan, 2003, pp. 82-89). Additional information on the importance of nursing morale, motivational factors and job satisfaction are addressed in Chapter 2.1 the Broader Survey, which includes a number of surveys’s and studies.
2.1 The Broader Survey
The annual RCN membership survey conducted in 2003 (Ball et al, 2003) found that the overall nursing population is getting older, with the media age increasing to 41 from 39 just five years ago. The respondent field consisted of a mailing of 15,917 RCN members with a 61% response rate, or 9,700 returned forms, thus the survey covered a broad number of members and it can be concluded that the sampling is an accurate cross section representing meaningful numbers that precludes bias. The significance of the foregoing with respect to the theme of this study is that the drop out rate for nursing students now stands at between 15% to 20%, with one out of ten of those surveyed indicating that they would not elect to work for the NHS (Ball et al, 2003). The findings indicated that the work hour demands placed on NHS nurses represents a real factor in dissatisfaction with their jobs in that 64% work full time averaging 44 hours per week as opposed to just 20% for GP nurses (Ball et al, 2003).
The significance of the foregoing in the context of this examination is that nurses indicated that they want greater choice and control over their working hours and cited this as a major factor in moving into agency and bank work where they work for a lower rate of pay, and usually the same hours and the same settings as NHS nurses. This represents an interesting correlation in that nurses elect these options even though they complain about the lower rates of pay for the same work and grades, however, they are more positive about their experience in bank and agency work than their NHS counterparts (Ball et al, 2003). The foregoing is borne out by the fact that nurses in NHS hospitals are less satisfied with their choices over shift lengths, as noted by 40%, as compared to 26% of GP practice nurses and 22% of agency and bank nurses, thus representing a key job satisfaction issue. The preceding is further evidenced by NHS nurses working in excess of their 37.5 contracted hours, averaging 44 hours per week.
2.2 The Critical Review
The RCN study uncovered that career prospects and the opportunity to progress are limited as three-fifths indicated that it was difficult to advance from their present grade, with E grade nurses as the most pessimistic (Ball et al, 2003). The lack of definitive job advancement opportunities represents a hurdle to motivating NHS nurses as well as recruitment, as do the survey findings regarding the following areas (Ball et al, 2003):
Table 2 – NHS Views of Workload and Staffing
(Ball et al, 2003)
Disagree
Strongly
Disagree
Agree
Strongly
Agree
Do not spend too
much time on
non-nursing duties
17
37
23
2
There are sufficient
Staff to provide a
good standard of care
21
40
23
3
I am not under too
much pressure at work
19
37
16
1
My workload is not
too heavy
23
39
13
1
The RCN study indicated that in terms of nurse’s issues, pay scales were not the overriding issue as factors such as workloads and hours worked played a large part in their perceptions. The study found that the respondents rated good pay as an important aspect by 75% of those surveyed, and 90% of the respondents stated that staffing was an extremely important issue and was one of the most cited areas by nurses to improve job satisfaction (Ball et al, 2003). The findings strongly indicated that as a result of dissatisfaction with working conditions that nurses were prepared to leave NHS jobs for less pay to gain control over their personal lives indicating the importance of job satisfaction as a key area. The lack of adequate opportunities for advance also rated high on the list of concerns and complaints voiced by respondents as 47% indicated that they were not graded appropriately (Ball et al, 2003). Pay scales are the outgrowth of the preceding thus naturally the attitudes towards compensation rated high on the list of replies.
Table 3 – Views Regarding Pay
(Ball et al, 2003)
Disagree
Strongly
disagree
Agree
Strongly
agree
I could not be paid more
for less effort if I left
nursing
35
39
10
1
Nurses are not paid
poorly in relation to other
professional groups
54
36
3
2
Considering the work I
do I am paid well
23
48
11
1
The replies in this area are consistent with the complaints regarding poor pay as voiced by NHS nurses as well as uncovered in numerous surveys and articles on this area, and nine of ten nurses feel that they are poorly paid in comparison with other professions (Ball et al, 2003). The importance of adequate pay was indicated by 75% of respondents, with 80% stating that receiving promotions based upon merit as equally important which represents a job satisfaction issue. Equating the factors representing motivation, job satisfaction and financial incentives in the nursing profession is an exceedingly complex task owing to the highly skilled nature of the work as well as the differing positions, grading and assignment variables involved. A significant measure of job satisfaction is the movement of staff in and out of the NHS. The study found that 25% of NHS nurses had changed jobs in the calendar year compared against 15% in the GP practice sector, and 17% involved in nursing and nurse education.
Table 4 – NHS Nurse Turnover 1996 – 2002
(Ball et al, 2003)
Year
Percent
1996
23%
1997
21%
1998
18%
1999
19%
2000
20%
2001
23%
2002
24%
2003
25%
It is important to note that in equating the preceding figures that a change of job does not always mean that one has left their current employer, as it could also mean a promotion, transfer or lateral move within the same organization. The survey revealed that 51% of the indicated changes in job represented a change in employer and that 13% of all nurses engaged in this practice during 2003 (Ball et al, 2003). The sheer overall size of the NHS means that most employment changes entailed jobs within the NHS system, with 96.5% of the nurses changing jobs who were in the NHS remaining in the NHS even though they switched or changed jobs (Ball et al, 2003), and these job changes can also entail the NHS bank. An important determinant of job satisfaction and motivation is what nurses plan to do in the future with regard to their employment. 29% of the surveyed nurses indicated their intention to leave their employer in the next two years, with NHS nurses indicated this intention at 27% (Ball et al, 2003). Those nurses who indicated that they intend to stay at the present employment cited that they felt that their work was valued as the primary reason, 63% (Ball et al, 2003).
Nurse’s views regarding motivation along with job satisfaction can be also equated via morale which describes their views as well as attitudes. The survey uncovered that 73% of respondents indicated that they did not desire to leave nursing as a profession, and of the 27% who expressed a desire to leave only 22% indicated that they would recommend nursing to others as a career (Ball et al, 2003). 74% indicated that the career prospects in the profession have increasingly become less attractive and a higher percentage would opt to leave the profession altogether if they could think of a suitable alternative after the years they invested in the career (Ball et al, 2003).
Table 5 – Respondents Indicating They Would Leave Nursing If They Could
(Ball et al, 2003)
Strongly
agree
Agree
Neither
Disagree
Strongly
disagree
Work is valued score
3.5
3.05
2.75
2.4
2.1
Table 6 – Respondents Indicating They Want to Leave Nursing
Percentages
(Ball et al, 2003)
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55
and
over
Would leave
14.7
23
31
32.5
27
33
30
26
Planning to
leave
5
9
10.5
9
7
7
11
34
The survey uncovered that the respondents who indicated a desire to leave the profession if they could was correlated strongly with their perception of a lack of advancement and or promotion opportunities. And those who feel that their work is valued indicated that they would either stay or did not indicate an intention or consideration of leaving. The preceding seemingly points to job satisfaction as the more important factor among nurses, feeling appreciated and valued, rather than low pay, which is cited often as a problem as well as advancement opportunities. Morale as well as being or feeling rewarded thus tends to fall closely with feeling valued and or appreciated as a reason for motivating nurses.
In terms of correlating the information and findings uncovered as a result of the RCN membership survey conducted in 2003 (Ball et al, 2003) the Kings Fund survey of ‘Morale and Motivation’ in the NHS represents a interesting manner in which to compare results to determine whether motivation for nurses is dependent on job satisfaction or financial incentives. The Kings Fund survey indicated that while it is difficult to measure the way in which individuals feel regarding their work, the survey indications pointed to morale as well as motivation in the NHS as being low. The Kings Fund survey identified three distinct factors that affect both moral and motivation (Kings Fund, 2002):
whether of not the staff feel they are valued,
the working environment, and
resources and pay scales
These same three aspects were correlations reached in the RCN membership survey conducted in 2003 (Ball et al, 2003) and thus provides a strong case for the fact that job satisfaction seemingly represents the key motivational factor for nurses in the NHS. The Kings Fund summary indicated that nurses as well as doctors have elected to leave their positions in the NHS as well as to retire early in large numbers (Ball et al, 2003). The preceding has been found to be in huge part that NHS staff members feeling that they are not valued by the government as well as the media, which has been critical of their performance and quality of service, which reflects in shaping public perceptions to a great degree. The Kings Fund (2002) survey points to the example of hospitals in the United States that have been successful in the attraction and retention of nurses which studies have attributed to their including staff in decision making aspects to increase their perception of value and worth as well as involvement and control.
The Kings Fund study indicated that the major factors that affect morale as well as motivation are as follows (Kings Fund, 2002):
Working Environment
The study found that the quality of the working environment which respect primarily to the staffing levels, speed of reform and the depth of same are major factors affecting morale as well as motivation. It indicated that too much change as well as too much political control represent de-motivating factors and represent key reasons that individuals indicate as desiring to leave employ in the NHS.
Feeling Valued
The RCN membership survey (Ball et al, 2003) strongly indicated the importance of ‘feeling valued’ in the workplace representing an extremely strong factor in job satisfaction. The Kings Fund study stated that the value which nurses as well as other staff members perceived as a result of groups outside of the NHS such as politicians, the public as well as the media were highly important in this equation. The Kings Fund study indicated that like the American hospitals, those NHS facilities that involve nurses in decision making, planning and policy have a happier and higher motivated workforce with lower turnover rates.
The Kings Fund study also included focus group discussions out of which ‘feeling valued’ emerged as the key determinant defining morale and motivation. The critical issues identified from these sessions where as follows:
Perceived Worth
The study uncovered that the general consensus among those in the focus group was that they did not feel valued as professionals by members of their own profession who had higher educational achievements or degrees, as well as the public.
Levels of Support
Staff members indicated that they feel that they are not supported by politicians as well as employers, citing that the public perception of the NHS had changed after the government blamed NHS staff for service quality. Importantly, those focus group members who reported and or felt they were listened to felt motivated.
Recognition and Treatment
The status of treatment, in terms of recognition and support was indicated as an important consideration by members of the focus group study with regard to their feelings concerning their job and satisfaction with it.
Job Satisfaction
Job satisfaction is a category that is in lock step with morale and motivation, according to the Kings Fund study, and represents reasons linked with the intention to leave or as to why they have left employment. The foregoing includes factors such as the nature of the work, if there are advancement opportunities and other factors linked to job satisfaction.
Resources and Pay
In this context, resources referred to how well the service segment of the hospital facility is resourced overall as well as the manner in which staff members are rewarded. The foregoing highly influences morale as well as motivation as reported by medical managers and doctors.
While some of the preceding areas seemingly do not correlate as being endemic to the examination of motivation and whether job satisfaction or financial incentives are the key to involvement for nurses, it was deemed important to draw a larger picture of the context to thus magnify the areas of importance within this context. The foregoing approach enables the research findings to draw upon additional information from which to support the rationales as well as aid in the formulation of the conclusion that the data suggests and points to. The foregoing also aids in the analysis of the primary research survey which represented a sampling of just 22 individuals.
Chapter 3 – Methodology
The methodology utilized in equating the examination as to whether motivation at work for nurses in the NHS is dependent upon job satisfaction or financial incentives was conducted utilizing primary research in the form of a small survey as well as secondary research surveys as conducted by the RCN, the Kings Fund, Margaret Callaghan (2003, pp. 82-89), and ‘The NHS Plan: A Plan for Investment: A Plan for Reform’ along with varied theories on job satisfaction and motivational factors. The utilization of five differing survey and studies on the subject were conducted to ensure that the conclusions drawn from this information was based upon having enough information from which to read into the examination. The secondary surveys and studies were both comprehensive as well as large and the topic field, while not specifically devoted to the examination as posed herein, did contain enough data, questions, elements and points to enable their use as viable information sources. Graph data was converted to tables herein to present the data in a more comprehensive and readable format.
The utilization of various articles and news sources aided in identifying the past as well as the current temper of conditions, moods and attitudes in the NHS from the perspective of nurses as well as governmental actions and public opinions. The preceding enabled the establishment of an historical perspective, and the legislative actions undertaken by the United Kingdom government in the form of the “The NHS Plan: A Plan for Investment: A Plan for Reform” (NHS, 2000) and the “NHS Improvement Plan” (Department of Health, 2004). The consensus of the overall effect of these plans is that the government has indeed made some progress in the hiring of additional nurses, doctors and technicians as well as introducing pay scale incentives, however, as stated by the BBC (2003) the NHS is still threatened with a shortfall of 50,000 nurses who are due to retire over the next five years despite the hiring of 40,000 extra nurses since 1997. The historical research utilized as part of the methodology provided background information on the internal problems of the NHS which includes the fact that a large proportion of the 40,000 hired NHS nurses were obtained through foreign recruiting and that the pay incentive measures only reached 15,000 nurses in terms of the 12% pay raise (BBC News, 2003). Wheatcroft (2006) summarized the preceding in stating that all of the additional funds that have been provided to the N
