Relationship between rewards and nurses' work motivation in addis ababa hospitals.

BACKGROUND: Nurses constitute the largest human resource element and have a great impact on quality of care and patient outcomes in health care organizations. The objective of this study was to examine the relationship between rewards and nurse motivation on public hospitals administrated by Addis Ababa health bureau.
METHODS: A cross-sectional survey was conducted from June to December 2010 in 5 public hospitals in Addis Ababa. Among 794 nurses, 259 were selected as sample. Data was collected using self-administered questionnaire. After the data was collected, it was analysed using SPSS version 16.0 statistical software. The results were analysed in terms of descriptive statistics followed by inferential statistics on the variables.
RESULTS: A total of 230 questionnaires were returned from 259 questionnaires distributed to respondents. Results of the study revealed that nurses are not motivated and there is a statistical significant relationship between rewards and the nurse work motivation and a payment is the most important and more influential variable. Furthermore, there is significant difference in nurse work motivation based on age, educational qualification and work experience while there is no significant difference in nurse work motivation based on gender.
CONCLUSION: The study shows that nurses are less motivated by rewards they received while rewards have significant and positive contribution for nurse motivation. Therefore, both hospital administrators' and Addis Ababa health bureau should revise the existing nurse motivation strategy.

Introduction

Human resource is a vital component for health organization in delivering health services (1). There are many factors that affect employee performance like: work conditions, employee and employer relationship, training opportunity, job security, and institution's overall policies and procedures for rewarding employees (2). Among those factors, which affect employees' performance, motivation that comes with rewards is of utmost importance (2). Motivation is an accumulation of different process that influence and direct our behaviour to achieve some specific goal (3). Rewards can be extrinsic or intrinsic, extrinsic rewards are tangible rewards and these rewards are external to the job or task performed by employee while intrinsic rewards are intangible rewards or psychological rewards (3).

In Ethiopia, even if the health service organization and management is decentralized, there is still a shortage of health professionals in different disciplines. This has a great deal of undesirable impact on efficiency and effectiveness of the health of the delivery services (4). High turnover is one of the major factors contributing to shortage of health workers (4). Based on World Bank report between 1995 to 2000 in Ethiopia 20% of health workers quitted from public hospitals and health centres and the first reason for high attrition rate was low salary (5). The study also revealed that 74.6% of medical doctors, 62.5% of pharmacists, 50.6% of nurses and 34.2% of laboratory technicians were not satisfied with their job because of the low remuneration (5). Nurses constitute the largest human resource element in the healthcare organizations, and have a great impact on the quality of care and patient outcomes (6), but there is a limited amount of literature in the area of relationship between rewards and nurse work motivation. The objective of this research is to examine the relationship between rewards and nurse work motivation in hospitals administrated by Addis Ababa Health Bureau. The study was guided by theoretical framework developed by Khan, Farooq and Ullan (7) (Fig. 1).

Figure 1

A conceptual model of motivation theory

Materials and Methods

A cross-sectional survey design using a quantitative method was conducted in five hospitals (Ras Desta Damtew, Zewditu, Yekatit 12, Menilik II, Gandi Memorial) which are administrated by Addis Ababa Health Bureau from June to December 2010. The participants of this study were midwives, clinical, public health, anaesthetic, ophthalmic, dental, psychiatric, and registered nurses who have been working in these five hospitals are working in these five hospitals. A list of 658 nurses meeting the inclusion criteria for the study was obtained from the Addis Ababa Health Bureau. The sample size of the study was determined by single population proportion formula assuming, 5% marginal error and confidence interval of 95%. . Fifty percent proportion has been preferred due to lack of similar studies in Ethiopia and accordingly the sample size was calculated to be 384. Accordingly, the sample size was calculated to be 384. The final sample size was calculated by using finite population number correction formula and considering 20% non- response rate, the final sample size was 290. A simple random sample was obtained by numbering the subjects from 1 to 658 and using a table of random number to obtain 290 subjects. Inclusion criteria for the sample were: They should be a worker in hospitals administrated by Addis Ababa Health Bureau, should have a working experience of more than one-year and should be a full-time worker.

The dependent variable for this study was work motivation and the independent variables were rewards (payment, promotion, recognition and benefit). The study was used closed ended questioner developed by De Beer (8) and TR Mitchel (9) to measure the independent and dependent variables. The questionnaire had two parts. Part one of the questionnaires was developed to obtain biographical information including: age, gender, educational qualification and work experience. The second part which comprises of items regarding two factors of nurses' work motivation including: internal (intrinsic) and external (extrinsic) and four variables of rewards: the direction of an employees' behaviour (Focus), the level of employee efforts(intensity), the way employee perform the task(quality), and the individual's willingness to behave despite obstacles(duration). Five points Lickert scale ranging from 1(strongly disagree) to 5(strongly agree) was used to measure their response. The respondent's scores for each construct were obtained by summing across all the item scores of the individual variation. The crombach's alpha reliability coefficients for the subsection of the questionnaire are as follows: payment(r=0.83), promotion(r=0.84), recognition (r=0.88) and benefit(r=0.85). Rehman also determined the internal consistency of the work motivation questionnaire and he reported that a coefficient alpha that is consistently high, ranging from 0.82 to 0.93(10). This suggests that the items of the questionnaire are relatively homogeneous with respect to the attitude construct they measure (10) reported (11).

Data were collected by five diploma holder nurses after they were provided a thorough training on data collection procedure. A strict supervision was made by the researcher during the data collection. Before data collectors delivered the questionnaire to respondents, they had explained the objective of the research including questionnaire returning date.

Statistical Package for the Social Sciences (SPSS) version 16 software was used for data analysis. Descriptive statistics was used for demographic information. Spearman's correlation coefficient and incremental regression analysis were used to determine the relationship between rewards (payment, promotion, recognition and benefits) and nurses' work motivation.

Ethical clearance was obtained from Addis Ababa Health Bureau ethical review committee, and permission to conduct the study was obtained from Addis Ababa Health Bureau. Verbal consent was obtained from every one of the participants before the data collection. Additionally, names of participants were not used in the study and confidentially of the respondents' information was maintained.

Results

A total of 230 questionnaires were returned out of the 290 questionnaires distributed to the respondents which made the response rate 80%.

Most of the participants 98(43.0%) were in the age group of 20–29 and 168 (73.0%) of them were females. One hundred thirty three (58.0%) had a diploma in nursing and over half of them 132(57.0%) had a working experience of 1–5 years (Table 1).

Table 1

Socio-demographic characteristics of respondents, hospitals administrated by Addis Ababa health bureau, August 2010.

Sociodemographic Variable	Total No. (%)
Age
20–29	98(43)
30–39	49(21)
40–49	60(26)
50–59	23(10)
Gender
Male	62(27)
Female	168(73)
Educational Qualification
Diploma	133(58)
BSc Degree	94(42)
Work Experience
1–5	132(57)
6–10	41(18)
11–15	18(8)
16–20	15(7)
>20	24(10)

The means for the payment, promotion, recognition and benefits ranged from 1.44 to 1.53. Results of the descriptive statistics in terms of arithmetic mean and standard deviation show that the mean values for all the variables are low. Low mean values of independent variables revealed that nurses are not motivated by the payment, promotion, recognition and benefit they receive. Compare to other independent variables, the mean value of payment is the lowest and this revealed that nurses are more de-motivated by the payment they receive. Furthermore, Mean value for nurse work motivation is 1.41 which show that nurses are not motivated overall (Table 2).

Table 2

Descriptive statistics of rewards and nurse work motivation in hospitals administrated by Addis Ababa Health bureau, August 2010.

Variables	Mean	Standard Deviation
Payment	1.44	0.74
Promotion	1.51	0.72
Recognition	1.53	0.67
Benefits	1.45	0.72
Nurse motivation	1.41	0.73

Spearman's correlation was performed to study the size and magnitude of the relationship between the variables. The relationships between rewards (payment, promotion, recognition and benefits) are positive and significantly related with nurses' work motivation (Table 3). Correlation coefficient between payments and motivation (0.74) is the highest among the entire variables and significant at 99% whereas recognition has a weakest correlation (0.29) among all variables but significant at 95.0% (Table 3).

Table 3

Correlation of payment, promotion, recognition and benefits with nurse work motivation in hospitals Administrated by Addis Ababa Health Bureau, August 2010.

Variables	Motivation	Payment	Promotion	Recognition	Benefit
Motivation	1.00
Payment	0.74**	1.00
Promotion	0.34**	0.30**	1.00
Recognition	0.291*	0.25*	0.02	1.00
Benefits	0.56**	0.60**	0.59**	0.47*	1.00

Correlation is significant at the 0.05 level,

Correlation is significant at the 0.01 level

The increment regression is performed by removing individual variables from the model and by checking the effect on the value of R-squared. Among all the variables removed, payment has decreased the value of R-squared to the highest degree from 79% to 62% (Table 4). The same result also obtained in goodness of fit in incremental regression after removing the payment. This decrease in value of the R-square by 17% shows the importance of payment in the model.

Table 4

Incremental Regression of nurse work motivation, hospitals administrated by Addis Ababa Health Bureau, August 2010.

Variable	OLS1	OLS2	OLS3	OLS4	OLS5
Payment	0.71**	-	0.77**	0.70**	0.77**
Promotion	0.11**	0.28**	-	0.13**	0.12**
Recognition	0.03*	0.11*	0.07	-	0.08*
Benefits	0.10**	0.69**	0.09	0.13**	-
R square	0.79	0.62	0.78	0.79	0.78
F-value	211.5**	125.5**	268.5**	282.5**	278.8**
D-W	1.675	1.76	1.66	1.62	1.64

* and ** indicates significance at 0.05, 0.01 level respectively

Discussion

Human resource is considered as the most important resource of an organization (2). Acquiring the right workforce and then retaining that work force is one of the challenges for health organization in developing countries (16). The results from this study reveal that there is significant and positive relationship between rewards and nurse work motivations. Among the independents variables payment is the most significant factor which affects nurses work motivation while recognition has the weakest correlation with nurses' work motivation. This finding also consistent with findings from other studies where Cashman and Gray found that doctors wanted autonomy and job status above a high income and regarded extrinsic benefits as less important while nurses wanted better monetary compensation more than anything else(12,13). Other research finding also shows that extrinsic rewards have a significant impact on nurses' work motivation while intrinsic rewards do not have much significant impact on nurses' work motivation (14). So, in absence of extrinsic rewards (payment, promotion, fringe benefit) which have been found to be the basic sources of motivation for nurses, intrinsic reward (recognition) appear to be less important for them. The result of the study also revealed that among extrinsic rewards, payment is an important tool for their motivation. On the other hand the mean value of payment compare to other variables revealed that nurses appear to be more de-motivated by the payment they are receiving. This finding is consistent with a research done in Ghana, where low salaries are the main source of dissatisfaction for health workers (15). The World Bank study also revealed that low salary is main cause for high attrition rate of health workers in Ethiopia public hospitals and health centres (5).

In conclusion, the finding of this study revealed that there is direct and positive relationship between rewards and nurses' work motivation. On the other hand, nurses perceived that their organizations are not offering right amount of rewards and this has created low-level work motivation for them. The effectiveness of health quality and customer satisfaction is dependent upon the motivation of its employees (16). Therefore, it is recommended that Addis Ababa Health Bureau together with other concerning bodies should revise the current reward strategy for nurses. Finally, further research could compare between private and public hospitals to see if the type of organization impact the relationship between rewards and nurses' work motivation.