Todd Dorman, M.D. FCCM
Johns Hopkins University, School of Medicine
Ronald Pauldine, M.D.
Johns Hopkins Bayview, Medical Center
Motivational incentives often are equated to financial or other material reward for performance; however material reward alone is rarely a sufficient motivating factor in achieving top performance. Long-term motivation is considerably more complex. In this article, we will review factors that frequently influence individual performance and discuss techniques that are useful in creating and sustaining a motivational environment for the entire ICU team.
The ability of ICU managers to positively motivate team members has vast potential to impact the quality of care delivered, the environment of care and individual team member satisfaction, thereby influencing retention and recruitment of team members. Creating a motivational environment is an art that requires managerial skill, an understanding of factors that are important to different groups of professionals as well as individual team members and compelling leadership.
Why Motivation Matters
The importance of understanding the principles of motivation for the ICU team is underscored by the influence a motivated staff has on a number of issues that are central to running a smooth and efficient ICU. This is especially true in the context of today’s highly competitive, resource-limited and workforce-depleted critical care environment. As we will see, a motivated staff should be a happy, satisfied and productive staff. If the motivational needs of the staff are met, retention and recruitment are likely to be enhanced. This, in turn, leads to savings in the cost and time associated with recruitment and training, lost productivity while searching for replacements, lost productivity while training replacements and the problems associated with resolving staffing issues while searching for new staff.
What Really Motivates Staff?
Incongruity between what managers and employees view as motivating factors has been well described. In past studies, managers frequently cited factors such as wages and job security as the key influences on their staff, while employees identified factors such as being appreciated and participating in meaningful work as the most significant issues to them (Thiedke 2004). This principle seems to hold true for healthcare workers as well, as money appears not to be the primary issue in physician turnover and dissatisfaction in both the United States and United Kingdom (Pearson et al. 2004; Weber 2005).
Understanding the factors that motivate employees is based on understanding fundamentals of human nature. Existing data appears to demonstrate that it is not really possible to directly motivate another person. Unfortunately, it is possible to de-motivate another person. It is therefore important to create working conditions under which an individual’s inherent motivation can surface and become explicitly expressed.
In general, the main force behind lasting motivation (and avoiding de-motivation) involves meeting the psychological needs of the individual, rather than providing material rewards. Factors that contribute to a positive work environment include: capable leadership, decent physical surroundings, acceptance of the individual into the team, individual recognition as a partner on the team, fair treatment, job security, knowledge and understanding of the effect on one’s efforts in meeting the organizational goals, knowledge and understanding of the organizational policies and procedures, recognition of special effort or achievement, respect regarding religious beliefs or cultural differences, assurance that all on the team do their fair share and fair monetary compensation (McConnell 2005). The extent to which these variables have importance and value to individual team members will vary considerably. Therefore, understanding the value system of individual team members can help the manager match motivating factors to the individual to optimize the environment for self-motivation and achievement.
In order to effectively motivate individual staff members, one must consider that each team member has unique motivational drivers, values and biases, as well as a different perspective on reasonable expectations and returns (Nicholson 2003). It is important to recognize that motivational factors may differ between groups such as physicians, nurses, respiratory therapists, patient aides and other support staff, and that the individuals within each group will likely weight specific factors differently. While the temptation may be to target strategies at specific groups, the value of understanding and knowing your employees as individuals cannot be underestimated.
Creating the Motivating Environment
It is evident from the above discussion that an understanding of the factors that motivate specific groups and individual employees is central to helping them meet their motivational needs, thereby helping to meet the needs of the organization. It may be desirable for the ICU manager to initiate changes in policies, procedures, work environment and leadership style with input from the team, in order to address issues that affect motivation and, indeed, issues contributing to de-motivation in the organization.
There are several factors that a manager must consider when instituting a culture of motivation in the ICU. It is important to create an environment that allows professional staff to achieve professional satisfaction and development, including clinical advancement, teaching or faculty rank considerations, research or opportunities for administrative and leadership duties. For many employees, an organizational culture that allows them to take pride in the organization through a mission and values that are centered on honesty and integrity will be important (Anonymous 2003). For professional staff in the ICU, as in other areas of healthcare, meaning is inherently obvious in the work. However, it is important to care for those at all levels of the organization and provide information on how their work matters and contributes to the end product (Shenkel and Gardner 2004). Open, accurate and frequent communication contributes to an environment where the efforts of the team are clearly valued and feedback is provided on how member contribution impacts the organization. Managers should consider whether the practice model and administrative support for the ICU team could be better aligned with employee expectations. Fairness and equity in compensation between peers is another area of concern. Some issues may be beyond the immediate control of the ICU manager, such as family issues related to geographic location or the ability to find satisfaction in the local community (Weber 2005). However understanding these factors may be beneficial to the ICU manager when designing a motivational work environment.
Several principles apply to implementing and evaluating the effort to create a motivational environment. Remember that reinforcement of behavior will encourage repetition and that faster responses to behavior will have a stronger effect on behavior in the future. Also bear in mind that positive incentives exert a stronger effect than negative incentives, or disincentives. Finally, it is critical to acknowledge that the importance of any particular motivational factor is subjective, and reactions will vary from one individual to another.
The fact is that most of your top people are selfmotivated and are not likely to respond to external incentives, but will be most likely motivated by addressing the factors discussed above. It is the ability to engage the less motivated players that creates the challenge and often proves to be labor and time intensive. Since change comes from within, it is the responsibility of the manager to understand the individual values of these potential problem employees (Nicholson 2003). What motivates them? What interferes with their motivation? Are you, as their boss, part of the problem? It is important to communicate directly and to carefully consider the array of possible outcomes. Remember that it may not be possible to meet the motivational needs and expectations of everyone.
Meanwhile, do not forget the needs of your most motivated team members. Obstacles to performance can create an environment that is de-motivating (Britt 2003). Make every attempt to set your people up for success. Provide the necessary resources and sufficient room for your staff to be creative and take chances without negative ramifications. Set the bar high, but have realistic expectations. Be careful to ensure that these highly motivated, valuable team members do not overwork themselves, in order to avoid burn out. The effective leader will help create an environment that recognizes good work and rewards excellence.