Incentives and intrinsic motivation in healthcare

2. Literature Review

2.1 Concept of Motivation

Research has indicated that motivation is an essential aspect of human behavior and cognition, catalyzed by internal goals, which can be influenced to increase people’s adaptability to novel tasks and situations (O’Reilley 2020). Also, Shah and Asad (2018) defined motivation as the process of influencing human behavior to obtain certain objectives effectively. Therefore, motivation can be operationalized in terms of goals influenced by reinforcement learning which treats people as passive beneficiaries of rewards and punishment. Based on this approach, motivation is influenced by providing or receiving as much reward as possible. Motivation is, therefore, defined as that which pushes people to act (Markus 2016).

Nevertheless, other studies have observed that motivation is driven by internal goals, besides accruing rewards. Further research has revealed that coordination of people skills, thoughts, emotions, and perceptions contributes to attaining goals or disengagement from seeking futile goals (Heckhausen & Heckhausen 2018). Motivation is, therefore, the universally recognized behavioral norms and needs, which include basic physical needs, and desire for control that instigates various motivates for doing something (Heckhausen & Heckhausen 2018). On the other hand, Kanfer, Frese, and Johnson (2017) described motivation as the observable changes in the initiation, persistence, intensity, and direction of voluntary actions. Baljoon, Banjar, and Banakhar (2018) explained motivation as the catalyst for work behavior which streamlines workers’ effort to achieve organizational goals. From an organizational point of view, work motivation comprises the integration of internal psychological processes and work environments, also known as transactional processes, and the balance between interactions of these processes.

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2.1.1 Importance of motivation

Motivation is important for the success of organizations, societies, and personal wellbeing. Previous literature on work-based motivation has revealed that nonability person attributes, for instance, traits, goals, and motives besides work ecologies and the various mechanisms and procedures involved in purposive actions, significantly influence employee performance (Kanfer et al. 2017).  Therefore, motivation influences skills that employees develop, the type of careers and jobs they pursue, and how they allocate resources such as time, social capital, attention, and effort to affect the persistence, intensity, and direction of activities within their work environment. Also, work-related motivation is the foundation of policymakers’ and organizations’ development of human resource management policies and practices, work environment, and promoting individual wellbeing

Managers of various organizations consider motivation a human mental characteristic that influences employees’ level of organizational commitment, which they leverage to achieve employees’ continued commitment to attaining organizational goals (Khoshnevisa & Abbas Tahmasebi 2016).   Besides, how an organization approaches employee motivation affects how various organizations offer their services. Literature on motivation in healthcare has indicated that leadership styles influence team motivation, especially in an increasingly turbulent and drastically changing healthcare system (Al Rahbi, Khalid, & Khan 2017). Team motivation in the healthcare industry helps complex adaptive organizations strive through a dynamic process that prompts leaders to examine organizations and leaderships from distinct points of view. Consequently, healthcare systems have become sensitive in preserving the commitment of healthcare professionals by investing motivational factors, especially those linking motivation to job satisfaction (Hayes et al. 2006). For instance, the Ukrainian healthcare industry motivates students to form and preserve healthcare culture by integrating various disciplines, including the safety of life, physical education, philosophy, and History of Ukrainian culture (Klymovych et al. 2019).

Motivation enhances volunteerism, which is indispensable for the adequate functioning of healthcare systems and maintaining the quality of care offered to patients (Bidee et al. 2017). Motivation influences volunteers’ feelings of well-being and engagement, improving individual satisfaction of basic needs for personal competence, autonomy, and relatedness. A study examining the influence of autonomous motivation of nurses in Italy indicated that perceived organizational support influenced job satisfaction because it directing improved commitment and nurses’ job autonomy (Galleta et al. 2016). Likewise, Berdud, Cabases, and Nieto (2016) noted that most employees in public organizations, including the health sector received a combination of incentives ranging from monetary to non-monetary to influence their commitment. Therefore, healthcare sectors optimally design incentive policies and schemes to offer healthcare professional competitive incentives likely to help them achieve self-actualization and hence enhance their long-term commitment to their roles.

More research has revealed that motivation remains one of the most effective measures of counteracting registered nurses’ work-related stress, dissatisfaction, and burnout. An inner dynamic interplay between registered nurses’ emotions, perceptions, and motivation and factors affecting good working relationship, for instance, progress (feeling of meeting expectations and achieving self-actualization), nourishment (interpersonal support from colleagues), and catalysts (particular actions that facilitate nurses’ actions and roles) (Ahlstedt et al. 2019).  Therefore, motivation enhances sustained high quality of healthcare services.

2.1.2 Sources of motivation

Extrinsic motivation is derived from factors outside employees to influence desired outcome (Putra, Cho, & Liu 2015; Shah & Asad 2018). These factors include, but not limited to monetary rewards, bonuses, job promotions, wage or salary increments, gift card, and paid vacation, among others. Research has indicated that there is a correlation between extrinsic motivation and improve employee productivity (Kuncoro & Wibowo 2019). On the other hand, intrinsic motivation is within an individual and often is based on perceptions that an individual’s job is interesting, meaningful, and challenging enough to offer self-actualization (Putra et al. 2015; Shah & Asad 2018). Intrinsic motivation plays an important role in improving employee’s work engagement (Putra et al 2015). Factors such as comfortable work environment and interesting and meaningful jobs increase employees’ intrinsic motivation, which catalyzes their willingness to engage in more work (Hee & Kamaludin, & Ping 2016).

Factors affecting the levels of effort by nurses working in major tertiary hospitals predominantly include internal self-concept motivation, goal internalization, external self-concept motivation, instrumental, and intrinsic motivations, respectively (Yahya et al. 2018). Internal-concept motivation result in in self-direction and adoption of behaviors that lead to higher levels of skills, autonomy, and ability (Hee et al. 2016). Internal self-concept motivation is realized when nurses’ feelings of progress and values are combined with performance. On the other hand, instrumentally motivated nurses associate behavior with organizational results, including promotion, salary increment, and/or reward (Proctol 2017). Similarly, nurses motivated by goal internalization find it easier adopting organizational goals and making them their own because they believe in them. Often, goal internalization motivation is influenced by factors such as work appreciation, job experience, access to substantial information, participation in decisions, and adaptability of organizational vision (Ongori 2007). Some nurses are motivated by external self-concept, which is based on seeking other people’s approval, including colleagues, to achieve acceptance and status. In other words, nurses motivated by external self-concept often seek social support from their teams besides feelings of being a valued health professional within a comprehensive team (Senek et al. 2020).

Emerging research on the factors influencing the level of work motivation of healthcare professional, especially nurses has identified personal and organization characteristics as critical in influencing nurses’ motivation (Baljoon et al. 2018). While motivation is essential in measuring health professionals’ commitment to health organizations, especially during challenging times, personal characteristics, including age, years of experience, autonomy, administrative positions, and level and system of education affect nurses’ motivation (Baljoon et al. 2018; Yardimci et al. 2017; Ngo-Henha 2017). Similarly, Afolabi, Fernando, and Bottiglieri (2018) observed that organizational factors influenced the motivation of healthcare professional in Europe, Africa, and Asia, and consequently, the efficiency, effectiveness, and quality of healthcare provided. The study identified conducive working environment, increased responsibilities, and communities’ appreciation of services delivered as the most important intrinsic organizational factors affecting healthcare professional’s service delivery.

In Pakistan, both male and female healthcare professionals, including doctors and physicians suffer work motivation not only due to poor renumeration but also unreasonable facilities at residence, limited supplies and inadequate medical facilities, political interference, and poor working environment (Shah et al. 2016). Although physicians joined basic health units hoping for security and convenient working hours, most of them, especially women struggle with inadequate and inconsiderate human resource policies, career growth structure, and performance appraisal besides disparity in renumeration with their male counterparts. Nevertheless, while cultural aspects influenced variability of organizational factors affecting motivation in different regions, renumeration, career advancement, and managerial support influenced healthcare professional irrespective of country or culture (Afolabi et al. 2018; Senek et al. 2020).

Past studies suggest that emotional laborers, especially social worker within the healthcare system, are susceptible to false-face, which inherently contributed to increased cases of burnout and low job-satisfaction (Roh et al. 2015). Social workers’ motivation is majorly intrinsic, particularly, commitment to public interests, which significantly improves their job satisfaction. Therefore, while scientific managements and public management concepts including division of labor and other organizational factors have been widely studies, emotions in workplace, especially in the healthcare industry, influence workers’ capacity to achieve organizational goals, and thus has to appropriate managed.

Previous literature on source of motivation for health professionals in low- and middle-income countries indicate that health sectors in these countries leverage performance-based financing (PBF) strategies to motivate (Lohmann, Houlfort, & De Allegri 2016). Although PBF is common, it affects intrinsic and extrinsic forms of motivation to varying degrees depending on the design, implementation, and outcome of PBF schemes. In essence, PBF influences structures of motivation, health professionals’ mindsets, behavior, and affect.  More studies revealed that poor job conditions and limited resources are predominant negative effects of motivation because they contributed to low job satisfaction among nurses working low-income countries (Ayalew et al. 2019; Hayes et al. 2006). While extrinsic factors including renumerations was still important in influencing satisfaction, intrinsic factors, including recognition, professional advancement, nurses’ work experience, and features of their job significantly influenced satisfaction of nurses working in low-income countries (Asegid, Belachew,& Yimam 2014).

2.2 Theories on motivation

Previous literature on theories of motivation have identified various motivational theories that explain the causal mechanism through which different factors influence individual motivation. Social exchange theory is one of the foundation motivational theories that link employee’s satisfying experience with their organization or job with likelihood of developing psychological attachment. In other words, social exchange theory is based on reciprocity (Ngo-Henha 2017), meaning that when management recognizes employees for extra work or helps them when in need, they would be inclined to act in ways that adds value to management, for instance, meeting performance goals (Wietrak, Rousseau, & Barends 2021). On the other hand, social identity theory asserts that motivation is exclusively dependent on self-interest but also on influence of self-categorization based on social characteristics such as race or invisible attributes like political affinity or careers, for instance nurses or job level or family member-role (Wietrak et al. 2021). Therefore, social identifies influence behavior of employees, depending on what they consider as more important. Likewise, social identities offer individuals sense of belonging hence enhancing self-esteem, self-efficacy, and self-confidence.

Self-determination theory of motivation is based on fulfillment of psychological growth and wellbeing of individuals through exercising autonomy over their actions and behavior, achieving competence in important tasks and activities, and having a sense of relatedness or being able to connect with others and feel that they belong (Wietrak et al. 2021). On the other hand, self-regulation theory borrows from self-determination but emphasizes on self-management of individual efficacy to guide individual thoughts, feelings, and behavior to achieve both short and long-term goals. Self-regulation motivated individuals leverage self-monitoring, self-evaluation, and self-reactions to desist from engaging in actions and activities that they are not supposed to engage in because they conflict organizational long-term objectives.

Reinforcement theory is based on classical operant conditioning in which behaviors accompanied by favorable consequences result in recurrence while behaviors accompanied by unfavorable consequences are less likely to recur (Wietrak et al. 2021). Based on reinforcement theory, people’s motivation is exclusively influenced by external stimuli and hence contradicts empirical evidence that people’s behavior might be in response to internal processes. Despite its myopic approach, reinforcement theory has been adopted by many motivational theories, particularly because it explains why various forms of incentives motivate employees. Contrary to reinforcement theory, drive theory asserts that people’s behavior, and hence motivation is influenced by internal stimuli or instinctual needs. The states that for individual to be satisfied or fulfilled, their physical, psychological, and sociological needs must be met. Therefore, people are intrinsically motivated to engage in activities and actions that meet their needs. From the drive theory of motivation, motivational factors are categorized into primary, which comprise of food, water, affection, security, and secondary factors, which predominantly socially learned or culturally predetermine, for instance, social approval, money, and status.

Another motivational theory is cognitive dissonance theory, which assert that when people hold two or more elements of knowledge that despite being relevant to each other are contradictory, they are often dissatisfied (Wietrak et al. 2021). The state of their dissatisfaction is referred to as cognitive dissonance, and hence are motivated to change the inconsistencies and corresponding behavior or attitude. In most cases, when employees’ performance is less than expected, they strive to achieve higher levels of performance to eliminate discrepancies between their output and what is expected of them.

Job characteristic theory states that people are intrinsically motivated to do their jobs to best of their ability when the following conditions, also referred to as job dimensions are met:  autonomy, skill variety, feedback, task significance, task identity (Wietrak et al. 2021). These dimensions influence three psychological factors of motivation, including experienced responsibility, experienced work meaningfulness, and knowledge of results which enhance job satisfaction, job performance, positive organizational outcomes, and low employee absenteeism.  On the other hand, expectancy theory postulates that people behave in a manner that derives specific results. Therefore, people’s motivation is influenced by assumption that their actions will result in certain performance, desired outcome, and whether the achieved outcome is valuable. In this case, financial incentives only enhance value the outcome but employee motivation is achieved if the can leverage their experience, skills, and self-confidence to achieve desired performance, trust in management, and perceived fairness in appraisals, believe that they will obtain financial rewards if meet expectations.

Studies have also emphasized discredited theories of motivation, which include Maslow’s hierarchical needs theory and Herzberg’s motivation theory. Maslow’s theory postulates that people are motivated to obtain certain needs, where some have higher precedence than others, and hence given priority such that they are satisfied first before satisfying lower-level needs (Wietrak et al. 2021). Needs are categorized into physical needs, including basic needs, safety needs (emotional security, social stability, predictability, financial security, and order, among others), love and belongingness needs (friendship, affection, trust, intimacy, acceptance), esteem needs (independence, self-esteem, dignity, status, achievement), and self-actualization needs (personal growth, achieving full potential, self-fulfillments, among others). While people seek self-actualization, basic needs take precedence. On the other hand, Herzberg’s motivation theory dictates that employees’ job satisfaction, which directly impacts performance, is influenced by intrinsic factors, also known motivational factors, responsible for improving job satisfaction, and external factors, also known as hygiene factors, that decrease satisfaction (Wietrak et al. 2021). Motivational factors are based on an individual’s desire for growth and they comprise of responsibility, achievement, the nature of the work, and recognition. On the other hand, hygiene factors are extrinsic in nature and comprise of deficiency needs which likely to result in employee dissatisfaction, for instance working conditions, salary, company policies, supervisory support, and interpersonal relationships (Hayes et al. 2006; Senek et al. 2020)

2.3 Concept of Turnover

Turnover is defined employee turnover as the rotation of workers in the labor market; from one occupation to another, and between jobs and firms or change in status between employment and unemployment (Ongori 2007). Therefore, turnover is a representation of a number of the ratio of employees that have left their jobs and organization within a given period of time verses visa-vie those still at the organization (Alla & Rajaa 2019). A later stud by Ngo-Henha (2017) defined employee turnover as the process of new employee entering an organization and the departure of existing employees.

2.3.1 Turnover Intentions

Although Ngo-Henha (2017) argued that turnover intentions are ambiguous, later literature associated intrinsic motivation is important in influencing employees’ intention to stay (Shah & Asad 2018). Turnover intention reflects one’s attitude towards his or her job or organization, which significantly affect decision to continue or leave their jobs or organization. According to Ngo-Henha (2017) turnover intention, also referred to as intention to quit or leave, is one’s conscious and deliberate willfulness to quit or leave his or her job or organization within a certain time. Turnover intention involves three major processes, namely; the thought of leaving the job or organization, the intention to seek new job opportunities, and the intention to quit. Therefore, turnover intention often results in actual turnover.

2.3.2 Consequences of high turnover

Turnover has costly implication for organizations. From an organizational point of view, high employee turnover is expensive, especially voluntary turnover, because it drains investment in human capital and the following process of replacing leaving employees takes more manifold resources (Shah & Asad 2018; Ongori 2007). Besides the cost of hiring and training replacements, turnover affects organizational output, which could be sustained at the expense of allocating more financial resources for overtime payment (Ongori 2007). In healthcare, nurse turnover could detrimentally affect an organization’s capacity to meet patient needs and the quality of healthcare (Hayes et al. 2006). Also, reiterated that high nurse turnover negatively affects the morale of the nurses and their former colleagues who have to find ways of integrating their replacement into their teams and orient them on their roles (Alla & Rajaa 2019; Hayes et al. 2006). Studies have revealed that turnover affects organizational profitability and management’s time when not handled well (Alla & Rajaa 2019; Razak et al. 2018). Moreover, losing an employee is not merely limited to loss of human and relational capital, but also intellectual capital as the competition gains the departing human, relational, and intellectual capital (Alla & Rajaa 2019).

2.3.3 Types of Turnover behaviors

Turnover is categorized as either voluntary or involuntary (Alla & Rajaa 2019; Ngo-Henha 2017; Ongori 2007), as well as internal and external turnover (Hayes et al. 2006). Voluntary turnover is defined as permanently releasing an employee from his or her role while involuntary turnover is defined as an employer exercising the right to terminate relationship with an employee (Ngo-Henha 2017). Also, turnover can be classified as either avoidable and unavoidable, where the latter is associated to reasons like retirement, family matters, or sickness (Ngo-Henha 2017). On the other hand, turnover can be desirable or undesirable where the former is attributed to employees leaving because of incompetence while undesirable turnover is characterized with talented, skilled, and competent employees leaving against employers’ wishes (Ngo-Henha 2017). Regardless of the type of turnover, organizational consequences are virtually indifferent because regardless of whether staff resign or are asked to leave, organizations incur costs. While turnover in other profession might be described as job move, turnover in nursing is described as leaving an organization or the profession (Hayes et al 2007)

2.3.4 Theories on Turnover

Ongori (2017) observed that voluntary turnover can be explained through the “folding model” that is based on the theory of decision-making, image theory, which asserts that voluntary turnover is influenced by an employee’s decision to quit. Image theory attests that people often leave their posts and organizations after analyzing their motivation to quit. On the other hand, the theory of organizational equilibrium (TOE) explains employee turnover intentions based on the assumption that there is balance between employees’ contribution and inducement with that of an organization (Alla & Rajaa 2019). Therefore, the theory states that employees’ decision to quit is based on the outcome of their analysis of their contribution to the organization visa-vie the organization’s contribution towards their lives (Ngo-Henha 2017). Therefore, based on TOE, perceived desirability to move and easiness of movements are considered the predominant factors of turnover intentions (Alla & Rajaa 2019). From the TOE point of view, job satisfaction depends on an employee’s compatibility with various assigned roles, predictability of personal relationship with the roles, and the conformity of what one does with self-image. According to Ngo-Henha (2017) there seems to be causal-effect relationship between turnover and the size of the organization, possibility of transfer, which also affects the desirability to leave.

.           Also, turnover intension can be explained through the social exchange theory which influence the relationship between social entities based on their ability to respect implicitly and explicitly agreed upon social rules and norms of exchanges that influence the rule reciprocity (Alla & Rajaa 2019; Ngo-Henha 2017). The rule of reciprocity dictates that one ought to get treatment similar to how he or she treats others (Alla & Rajaa 2019). Therefore, based on social exchange theory, employees are connected through a network of work relationships which influence their intentions to either keep a job or quit (Ngo-Henha 2017). Non-respect of implicitly or explicitly agreed rules by either co-workers or management catalyzes turnover. On the other hand, employee turnover intentions can be explained through the job embeddedness theory which states that employees have several connections in their organizations and communities, which they fear losing or sacrifice to seek new career opportunities (Alla & Rajaa 2019; Ngo-Henha 2017). Also, giving up familiar colleagues, good day care, easy commute, and good club membership influence employees to stay in their jobs because they feel embedded to their social and professional environment (Ngo-Henha 2017)

Herzberg’s two-factor motivation-hygiene theory postulate that employee’s turnover intention can be influenced by motivation factors, which affect job satisfaction, and hygiene factors, which catalyze job dissatisfaction (Ngo-Henha 2017). According to Herzberg’s two-factor motivation-hygiene theory, an employee’s response to turnover intentions increases when factors that his or her overall satisfaction are negatively affected. Another theory that explains turnover intentions is the resource-based view which states that resources (capabilities, assets, organizational processes, and information) that influence performance advantages are rare, non-substitutable, costly to imitate, and valuable (Ngo-Henha 2017). As a result, they help an organization achieve competitive advantage. Therefore, employees are likely to stay in their jobs as long as the feel valued and treated as special, otherwise, they start entertaining turnover intention appeals.

The Equity Theory provides rationale for turnover intentions based on the notion that feelings of equity and fairness in work environment motivates employees’ productivity. According to the Equity Theory, employee’s satisfaction depends on exchange relationship where they offer their effort with expected outcome. Therefore, when analyzing the value of the outcome against their input, employees can determine the equity or inequity associated with other reference groups, including colleagues doing the same job. Employees will strive to achieve equity where they feel there is inequity through altercation of input, including skills, experience, and effort. Also, turnover intentions can be explained through the human capital theory that states that factors such as level of education, training, and knowledge directly influence employee productivity. Consequently, organizations are likely to invest in employee development to increase productivity. Nevertheless, employee education and training enhance their employability in the job market, which increase their turnover intentions for better opportunities. Lastly, employees’ desire to leave can be explained through the Expectancy-Confirmation Theory that postulates that people often have expectations before taking action. Therefore, if their expectation is positively met, it increases their satisfaction, and vice versa. An analysis of expectations before and after the event determines satisfaction levels. When employees, enter organizations, they look out to see if their expectations and values are met, affecting their decision to stay of they are met or leave if otherwise (Ngo-Henha 2017).

2.3.5 Factors influencing turnover intentions amongst staff in the health care industry

Research on the consequences of various forms of motivation on nurses’ commitment to offering quality healthcare services have revealed that prosocial factors of motivation, especially willingness to help reduce suffering, including in formal settings, are arguably the best reasons for being a nurse and result in better outcome for both patients and nurses (Dill, Erickson, & Diefendorff, 2016). Therefore, extrinsic forms of motivation for caregiving are presumed to result in sub-standard outcomes merely because they deviate from prosocial model of caregiving. These contrasting sources of motivation for caregiving have varied consequences on nurse burnout and turnover intentions. Highly Intrinsically and extrinsically motivated nurses have better employment and health outcome because they are likely to experience lower burnout, less likely to leave, and experience less negative physical symptoms compared to their counterparts with higher prosocial motivation who are likely report job burnout. Early literature on turnover intentions cited emotional exhaustion and work design challenges as the common reasons for increased nurse turnover in Canada, England, the USA, German, and Scotland (Hayes et al. 2006)

Emerging studies postulate that job burnout and pay satisfaction significantly influence intrinsic motivation and turnover intention among geriatric nurses working in nursing homes (Hayes et al. 2006; Lasater et al. 2021; Wang et al., 2019). Also, Ngo-Henha (2017) discovered that factors like annual pay, though important, were not significant mediators between intrinsic motivation and pay satisfaction among geriatric nurses working in the nursing home settings. However, intrinsic motivation substantially influenced geriatric nurses’ turnover intentions (Wang et al. 2019). While pay might be low, geriatric nurses’ job was found to be very rewarding in terms of helping nurses achieve the expectations and values, including emotional intimacy, meaningfulness of working closely with the elderly, and fulfilment of moral obligation. Burnout contributed to turnover intension as opposed to intrinsic motivation because it is presumed that intrinsically motivated geriatric nurses have freedom of choice, making decisions, and seeking devotion in their work, and enjoy positive emotions of fulfilment from their work. Likewise, they are more likely to be more satisfied with their wages. Contrary, their counterparts in the health tourism are motivated by career development, job enhancement, and autonomy (Ngo-Henha 2017) coupled with interventions such as training, guidance, counselling (Hee et al. 2016), promotional opportunities, and work schedules (Hayes et al. 2006)

Leadership, work environment, compensation, and job satisfaction jointly or to some degree, influence turnover intentions among employees by 67% while the rest is influenced by other factors. However, job satisfaction ranks as the greatest contributing factor of turnover intentions (Hayes et al. 2006; Ongori 2017; Santoni & Harahap 2018). Turnover intentions can be lowered when employees are satisfied by the work itself, not merely the fear of not getting a better job (Hayes et al. 2006; Ngo-Henha 2017). Their feelings of satisfaction can be reinforced by both internal and external factors such as improving compensation or sense of security or good leadership based on participative managerial activities (Santoni & Harahap 2018). Similarly, Shah and Asad (2018) asserted that Perceived Organizational Support (POS), an important leadership attributes, mitigates voluntary turnover because it enhances employee commitment based on the belief that their high performance will be recognized and result in rewards to enrich their wellbeing.

Besides, other organizational factors, including organizational instability, unfair labor practices, inefficiency, increase turnover as employees will feel the need to seek for stable working environments that can support their career development (Hayes et al. 2006; Ngo-Henha 2017; Senek et al. 2020). Also, strong communication systems, where employees are not only informed but also participate in some degree of decision-making experience less turnover compared to organizations with poor personal policies and poor motivation (Ongori 2007). Likewise, Hayes et al. (2006) observed that professional commitment is effective in influencing nurses to leave the profession than the organization

2.3.6 Initiatives put forward by the NHS to reduce turnover intentions

Retaining of nurses in the NHS is growing concern in the United Kingdom’s health sector following the increasing turnover rates attributable to a wide range of factors (Department of Health 2015). Some of the prominent pull or positive factors influencing nurse turnover include nurses’ desire to increase their skills and knowledge of other specialties, seeking opportunities for training and progressing in their career, potential for a grade 6 career pathway, better work and life balance, promotion, better financial reward for a similar post in the NHS that is graded differently elsewhere, and higher pay rates for similar post working as a temporary staffing agency nurse. On the other hand, negative reasons of nurse turnover include renumerations and cost of living, attitude of patients and their relatives, management practices, the effect of nurse vacancies, and working patterns, staffing, and patient acuity. Ongori (2007) simplified the negative reasons for turnover as job- related stress, lack of commitment in the organization, and job dissatisfaction. Besides, Ongori (2007) asserted that personal factors such as locus of control, sense of powerlessness, and personal control influence substantially influence turnover.

According to Buchan et al. (2017) the problems facing the NHS are not isolated but rather symptoms of a lack of clear and comprehensive workforce strategy. The Covid-19 pandemic exposed most of the underlying challenges facing the NHS, including underfunding, workforce pressure, and increased demand on staff to deal with increasing infection rates (Bakerjian et al. 2021; Buchan et al. 2017; Lasater et al. 2021; NHS Providers 2020). Before, the first wave of the COVID-19, hospital nurses were experiencing burnout and worked in understaffed conditions and therefore, posing risks to patients (Lasater et al. 2021). In April 2020, the Center for Medicare and Medicaid Services launched the Coronavirus Commission for Safety and Quality in NHs to address the pressure that the staff endured in providing healthcare services aimed at improving safety procedures, infection prevention and control, and quality of life of people in nursing homes (Bakerjian et al. 2021). The dedication of NHS staff has been outstanding throughout the pandemic but there has been increasing reports of burnout which has alarmed 99% of trust leaders who are extremely or moderately worried that the staff overstretched beyond reasonable limits (NHS Providers 2020).

There has been a decline in the number of nurses in the NHS, particularly mental health and community health nurses (Marangozov, Williams, & Buchan 2016). For instance, in 2016, the NHS in England registered a shortage of 29, 000 FTE (full-time equivalent) staff, where 1 out of 10 represented nursing vacancies (Buchan et al.2017). One of the predominant factors of declining number of nurses in the NHS is the increasing number of nurses leaving their jobs before retirement age. Buchan projected that approximately 84, 000 nurses were expected to leave their job by 2022. However, in July 2017, the NHS England rolled out the National Retention programme across 145 Trusts and general practices to retain approximately 290, 000 hospital staff (Ely 2019). The scheme included motivational features, for instance, a transfer window to give staff opportunities of moving to different areas in the NHS to improve and diversify their skills, mentoring programs for new recruits, and incentives like gym memberships. The scheme resulted in 800 fewer nurses leaving their jobs and reduced nurse turnover to 12%.

Besides, the NHS is increasing its intrinsic motivation strategy by reducing bureaucracy and simplifying of regulations so that staff can exercise autonomy in working flexibly and developing new skills in new areas (NHS Providers 2020), which could be significant in achieving job satisfaction (Hayes et al. 2006). Besides, some of the recommendation likely to decrease turnover intentions include supporting newly qualified nurses through supportive transition or development programs, enhancing team cohesion, and adopting team-based intentions (Halter et al. 2017)

Some of the recommendation on how to address the increasing nurse turnover in the NHS include the adoption of effective and coordinated workforce policy based on training and motivational factors to retain the current nurses (Buchan et al. 2019). Rightly so, the NHS has welcomed the help of fast-tracked students besides the returning of NHS staff who had previously left the health organization (NHS Providers 2020). Moreover, provision of flexible working hours, new pay systems, restricting the pay system and career structure besides access to education could help improve nurse rentention (Marangozov et al. 2016). Also, Bakerjian et al. (2021) recommended that the NHS should consider 24/7 registered nurses coverage and competitive compensation to increase motivation of nurses, ensure registered nurses have geriatric nursing and leadership skills, and increase effort towards recruiting and training more registered nurses. The NHS has been prompted to adopt international recruitment to address nurse shortage but this strategy is constrained by uncertainties of Brexit and broader immigration policies (Buchan et al. 2019). Besides, The NHS has adopted a new policy of nurse recruitment that includes nurse associates, Nurse First scheme, and nursing degree apprenticeship (Jones-Berry 2018). Further research on potential initiatives to minimize turnover show that nurse turnover can benefit organizations in cost-saving but also offer nurses opportunity of matching their skills with jobs where they can efficiently contribute to the labor market, hence increasing productivity (Hayes et al. 2006).

2.4 Research Gap

While there is an increasing interest in the increasing turnover in NHS because of wide range of organizational problems, there is lacks enough literature detailing the influence of motivation and satisfaction of nurses in turnover intentions and actual nurse turnover. Also, there is insufficient literature on the influence of covid-19 pandemic on nurse turnover intentions.















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