Chpater II Review of Related Literature This chapter consists consists of literature review discussing various factorsrelated to the issues presented in this study. The review aimed at identifying, clarifyingand establishing factors and related issues that may affect positively or negatively theperformance of nursing staff in an organizations. Health-care delivery is highly labour-intensive. The quality, efficiency and equityof services are dependent on the availability of skilled and competent healthprofessionals when and where they are needed. It is essential that health workers beapproprieately trained to deliver the required services according to set standards. Dueto critical shortages of certain key health workers, the challenge to health authorities isto ensure that the available health workers are appropriately skilled and motivated toprovide effective health-care services to populations living in a vast geographical area. Itis important now, more than ever, to assess the factors that positively and negativelyaffect the performance of health workers to ensure that they are optimally utilised.Theoretical Framework Burns and Grove (2003:155) define a theory as “…an integrated set of definedconcepts and statements that present a view of phenomenon and can be used to doone or more of the following: describe, explain, predict, or control the phenomenon”.Conceptual models are similar to, but more abstract than theories; each model
“…broadly explains phenomena of interest, expressess assumptions, and reflects aphilosophical stance”.The Bennett and Franco’s model on work motivation Bennett and Franco (1999:4) proposed a conceptual framework of factors thatinfluence work motivation; the factors are identified as individual, organizational,broader social and cultural factors. This model, as illustrated in Figure 1.1, focuses onmotivation as the main factors that influences the level of performance of healthworkers.Individual or internal motivation process The individual or internal level is described as a process in which variousdeterminants such as the workers’ need, self-concept, expectation and perceptionsabout own work capability may lead to performance outcome. The organiztion, on theother hand, should provide the necessary inputs such as supplies and logistics, as wellas an efficient supportive system and environment for the worker to influence motivationthat will trigger good performance (Bennett and Franco 1999:4). The outcomes ofmotivation are mainly affective, cognitive and behavioural (Bennett and Franco 1999).Social and cultural factors The Bennett and Franco framework emphasises the fact that apart from internalfactors, there are a number of other complex factors that significantly influencemotivation. These are social and cultural factors and include issues such as communityexpectations, peer pressure or social values of health workers and health managers
which may also contribute to an individual’s motivation to work. The reason is thatindividuals are part of a larger community and may reflect the cultural beliefs of thatparticular community which may conflict with those of the organization; individuals’values are assumptios of their community in the workplace. Wider cultural values maytranslate into specific types of work behaviour that clash with certain organizationalpolicies. Individual workers whose values do not correspond to those of the organizationmay be less willing to personally commit to the organization (Bennett and Franco 1999)Organizational factors Organizational factors that are liked to the day-to-day environment in whichhealth workers carry out their duties and which may affect the level of performanceinclude aspects on internal organizatinal structure such as clearly-articulated goals, thehuman resources management style, information with regard to norms and standards,and support to the employee. Issures such as delegation of authority, autonomy inundertaking tasks, supervission, systems of feedback, and availability of resources alsoaffect staff motivation (Bennett and Franco 1999). The interconnection between the social, individual and organizational factors hasbeen recognised as a dimension of motivation that can eventually affect performance.According to Bennett and Franco, the role of the organization is to communicate itsgoals, the processes and resources for achieving these goals; additional goals are toestablish a system of feedback and to develop staff knowledge and skills. Zurn, Dolea and Stlwell (2004), supports the notion of Bennett and Franco thatmotivation at work is generally believed to be a key factor in individual performance.
They acknowledge that evidence supports the connection between job dissatisfaction,lack of motivation and intention to quit. They also stressed that since health caredelivery is highly labour-intensive, health sevice quality as well as efficient an equitabledistribution therefore will depend on health workers’ willingness and ability to committhemselves to their task. Zurn et al (2004) believed that capability of staf to attend totheir jobs (Knowledge, skills and experience), motivation of staff to put effor into theirwork and organizational support and opportunities, including a physical and socialenvironment conducive to work plays a key role in performance of health workers.Sharpley’s model on perception, motivation and performance Sharpley (2002) proposed a model, as depicted in Figure 1.2, that centeredaround three individual factors as the most important affecting the interventions ofhealth workers. These differences are perceptions – self-belief, anticipation of successand critical thinking; experience of work – personal impact, meaningful work, feedback,and discretion; and work outcomes – job satisfaction, work stress, empowerment andmotivation. These factors are seen as the differences in individuals that affects theirexperience ate work. Organizational factors are equally important and support the interventions ofindividuals. The Sharpley model also considers organizational factors such asmanagerial support; colleagure and supervisor support as well as organizational cultureassociated with high performnance. Sharpley sees individual perceptions, individual experience of work and workoutcomes or achievements as improtant for work motivation and positive performance.
According to him, differences in individuals affects their perceptions and are significantlylinked to work demand. The manner in which individuals react differently to workdemand, setbacks or disappointments is important and should be considered in order toget insight into issues that affect motivation and performance (Sharpley 2002). According to Sharpley (2002), the most imprtant aspect of high performance isthe appreciation of one’s role, i.e. understanding and knowledge of the differentprocesses of individual or manager roles.The Performance Model For the purpose of this study, a combination of conceptuial framework of Bennettand Franco (1999) and the model of Sharpley (2002) will be used as the theoreticalbase. It will be called the performance model, as illustrated in Figure 1.3, and willconsider the following dependent factors: social factors which include expectation fromthe community, peer pressure, culture beliefs and social values; individual factors thatinclude issues of individual perception, expereince of work and individual workoutcomes; and organizational factors that include issues of managers’ support andperformance management, organizational culture, norms and standards used at work,communucation, supervisor and colleague support. All of these factors affect thecapability of health workers to perform a certain task positively or negatively. Nickols (2003) and Fort and Voltero (2004) identify similar factors that are closelyrelated and affect provider performance in the workplace as indicated by theperformance model. They include clear goals and job-expectations, suitable repertoire,immediate feedback, skills to perform, knowledge of organizational structure, functionial
feedback system, sound mental models, sufficient motivation through self-satisfactionand incentives, supportive or conducive environment, and manageable tasks. The performance model will guide the study and the development of strategiesand a framework for enhancing the performance of health workers. According to thismodel, the variables and processes affecting performance of health workers wouldinclude job expectations or design; goals and objectives; organizational culture andsupport; management style, feedback and communication; and the physicalenvironment. Intrinsic factors, such as motivation, self-perception, values and beliefs,incentives, rewards and employee benefits, knowledge and skills, are also important. According to Price (2000), in order for an organization to operate effectively, aharmony between strong, goal-oriented leadership; high levels of employee motivationand skills; holistic approach to management and organizational change; and perceptionthat employees are regarded as valuable human capital must exist. Rafferty, Maben, West and Robinson (2005) and Mutizwa-Mangiza (1998)emphasise that environmental and organizational factors may negatively or positivelyaffect performance of health workers. Environmental or external factors include politicalpressure and health-care reforms, financial pressure, decentralisation of health caresystems, client pressure, and quality assurance and changes in health professionaleducation. Organizational or internal factors include human resources managementsystems (effective planning, policy, skill mix, industrial relations, and skill retention),focused team work, organizational structure, mangament skills, performance standards,norms and values. Other internal factors incldue performance appraisal systems, input
by all stakeholders in regulatory and policy procedure development, mutual supportiverelationship salary and incentive structure, sufficient staff and equipment, personnel andcareer development. The theoretical frameworksand performance model distinguish various individual,organizational and social factors that may various ways affects the performance ofhealth workers. It can be assumed that the critical functions of an organization areidentifying the factors that impact on performance and seeking sp;utions and innovativeinitiatives that empower staff and boost performance. Nogueira and de Santana (2003)emphasise that it is important for an organizations to put in place sound humanresources management systems, provide necessary policy and regulatory frameworksand ensure conducive working environments for workers.Human Resources Management Human resources management deals with the aspect of managing peole instrategic, coherent and integrated way. According to Swansburg (1999), management“…means accomplishing the goals of group through effective use of resources”, and“…managing is the art of doing” while “…management is the body of organizedknowledge underlying the art”. Human resources or people are the most valuable assets of an organization.They are the ones that make things happen, and they influence all inputs in anorganization, whether they are managerial or operational (Hendry 1995). Human resources management includes all processes that affect the relationshipbetween an organization and its employees and is geared towrds achieving the
organization’s objectives (Price 2005). Human resource mangaement is also seen as apolitical regulatory function that mediates between a bureaucracy and the ethical andpolitical goals embedded within an organization;s mission (Nogueira and de Santana,2003). In the public sector, human resources management workds closely with thegovernment civil or public services to ensure that policies, regulations and conditions ofservices are implemented and adhered to (WHO 2005). In view of the aforementioned,it can be concluded that the function of human resources management broadlyconstitues all organizational policies and strategies concerning human resourcesmanagement. These includes the formulation of human resources policies within theoverall health policy; developing of macro-plans and micro-plans for development ofhuman resources for health; education, training, skills and competency development;human resources management; regulation of health professions; and research.Planning and Policies Formulating human resources policy is an expression of commitment to guidehealth personnel towards achievement of the goal (WHO 2003). Human resourcesplanning, on the other hand is the process of anticipating future staffing needs andhuman resource-related actions to ensure that a sufficient pool of skilled and motivatedpeople with the right skills mix and experience will be available to meew theorganizational need in the long term (O’Brien-Pallas, Birch, Baumann and Murphy2003). Health services and human resources policies and plans are key instruments for
implementing decisions affecting the type of human resources for delivery of healthcare. Human resources policy formulation and plan development are important factorsin the human resources management process (WHO 1998). However, in many cases,there is a mismatch between human resources management policies and theirimplementation (Bach 2001); in many countries these plans are not approved andcosted (WHO 2003).Staff utilisation and retention Deployment, equitable distribution and utilisation of appropriate staff to match theorganization’s strategies remain important aspects of human resources management.These aspects are important because they guide the effective distribution, deploymentand utilisation of appropriate staff by placing them in the right jobs and retaining themwhere the are most needed (Price 2000).Working conditions and work environment According to Bezuidenhout (1994), working coditions refers to “…the interactionof an employee with the physical work environment”. Working conditions includephysical conditions such as working tools, equipments, materials, and schedules.Psychological conditions include work pressure and stress, and physical layout refers toa clean and comfortable environment. Working conditions have been singled out, along with remuneration, asone of the major demotivators and are often the reason why professional nurses leaves
the profession (Awases et al 2004). This view was verified by a report made byCanadian Student Health Research Forum (2001) which identified work pressures andsafety as some of the issues affecting nursing work environment. The report stressesthat nurses’ work demands put extreme pressure on them and do not correlate withtheir skills and knowledge. At the same time, the continuous understaffing results inoverburdening available staff with heavy workloads. Regarding workplace safety, thereport shows a relationship between staff shortage, heavy workload, stress and injuriessuch as musculoskeletal injuries, low-back pain and injuries from sharp objects.Motivation According to Swansburg (1999), “…motivation is a concept used to describe boththe extrinsic conditions that stimulate certain behaviour and the intrinsic responses thatdemonstrates that behaviour in human beings”. Motivation is seen as the most crucialworker’s attribute for improving performance and includes a mix of complex factors suchas personal values, professional ethics, incentives, workspace and environment )JointLearning Initiative 2004). Two types of theories of motivation have been identified and concern content andprocess. Content theories focus on individual needs that strengthen, prolong and leadbehaviour. Aspects that motivate nurses may include issues of psychological need forsafety, respect and status that may lead to self-respect and self-fulfillment. Otherindividual cognitive needs include need for knowledge and understanding, feeling ofbelonging, and issues of job security, fair working conditions and interpersonal relations.
Maslow’s need hierarchy and Herzberg’s motivation-hygiene theory are some theoriesthat relates to the content theory (Swansburg 1999). The process theory of motivation is also called behavior modification. It is basedon the notion that learning occurs because of behaviour; it advocates for reinforement ofgood behaviour through reward, praise and recognition. Reinforcement motivates andimproves the strength of a response, and undesirable behaviour should be modified andnot punished (Swansburg 1999).Sirota (2002) identifies three promary goals that motivate people at work: equity,achievement and camaraderie. These also support the content and process theories.He called this the “Three-Factor theory of human motivation in the workplace’ and itincludes: Equity: employees would like to be treated justly in relation to the basic conditions of employment. These basic conditions include physiologic needs, that is, safe working conditions, reaseonable workload and comfort; economic needs of job security, satisfactory remuneration and benefits; and psychological needs of respect, good interpersonal relations and credible management. Achievement: employees want to take pride in their accomplishments by doing a job that matters to them; to receive recognition for their accomplishments and take pride in the organization’s acheivements. Camaraderie: employees wish to have warm, interesting, and cooperative relations with others in the workplace.Remuneration and incentives
Hicks and Adams (2003) defines remuneration as “…the total income of anindividual and may comprise a range of separate payments determined according todifferent rules”. The WHO (2000) defines incentives as “…all rewards and paymentsthat providers face as a consequence of the organizations in which they work, theinstitutions unde which they operate and specific interventions they provide”. Financial incentives consist of pay, other direct financial benefits (such aspensions, health insurance, dependent allowance, clothing/housing allowances,hazzard payments) and indirect financial incentives include flexible working hours,sabbaticals, study leave, planned career breaks, occupational health and counseling,acess to support for training and education (Hicks and Adams 2003). Payment and incentives are seen as having a profound effect on performance.According to the WHO (2003), raising wages in developing countries where workers arepaid less than in developed countries will increase productivity; however, it may be lesssuccessful in countries where salaries are already high. Nonetheless, increaseingwages and other non-financial benefits such as accomodation, transport, on-the-jobtraining and opportunities for promotion and rotation has been shown to increaseproductivity. According to the Canadian Student Health Research Forum (2001), there is arelation between nurses’ satisfaction with their salaries and their job satisfaction;however, the salary becomes an issue of concern usually in the absence of otherfactors of satisfaction such as recognition, opportunities for personal development andgrowth. The current situation the Philippine region portrays a picture of poor
remuneration packages and low wages in quite a number of countries. There existmajor differences in salaries between countries. For instance, it was found that ageneral practitioner is paid 150 to 200 US$ per month compared to US$700 in anothercountry (WHO 2003).Human resources development models Price identifies two models that are influential to the development of humanresources management. The Harvard model emphasises the soft approach andprovides a strategic map which guides manager-employee relationships. This approachincludes characteristics such as motivating people through their involvement indecision-making, creating an organizational culture based on trust and teamwork,supporting the notion that people can influence the outcome or achievements of anorganization. According to Hendry (1995), the Harvard model of human resourcesmanagement includes an integrated framework of personnel mangament. This isindicated in the fact that both forms of management recognise the tense relationshipbetween corporate needs for contril and individual needs for personal achievement. On the other hand, the Michigan model focuses more on the harder resources.This approach advocates that people should be treated like all other resources in anorganization: they should be obtained cheaply, used scarecely, developed andexploited. This approach develops human resources policies and strategies thatcombine the available human resources with the organization’s goals. The matching ofavailable human resources to achievements is done through regular restructuring,performance-related pay and downsizing (Price 2000).
A paper by Bucham (2004) aimed at looking at how human resourcesmanagement has been defined and evaluated in non-health sectors compared to thehealth sector in the United Kingdom stresses the uniqueness and complexity of humanresources management in the health sector which somehow supports the MichiganModel. For example, the organizational context is different from other sectors.Performance is mainly assessed with health sector-specific indicators such as clinicalactivities, workload, measure of outputs, patients treated, or mortality rate. An importantaspect of human resources for health systems management is the need to matchinterventions with context, characteristics and the priorities of the organization (Bucham2004). According to the Canadian Student Health Research Forum (2001), thechallenge of human resource management policies is to create a conducive workingenvironment or healthy workplace that will enhance the work of the nursing workforce. Akey strategy to enhance the work of staff in an organization is performancemanagement.Performance Management Performance management is one of the most important and critical functions ofhuman resource management. It is seen as a way of establishing mechanisms forreviewing the performance of staff, and helping them to effectively contribute towardsthe achienvement of organizational objectives (Price 2000) Katz and Green (1997) define performance management as “…a systemcomposed of an orderly series of programmes designed to define, measure, and
improve organizational performance”. The Public Service and Merit ProtectionCommission (2000) defines performance management as “…helping people to workmore effectively by improving individual and team performance, increasing the overallproductivity of an agency” in the context of the staff management. The Institute ofPersonal Management as quoted by Martinez (2003) defines performance managementas “…a strategy which relates the evey activity of the organization set in the context ofits human resources policies, culture, style and communications systems. The nature ofstrategy depends on the organizational context and can vary from organization toorganization”. Performance management is a shared process between managers, the individualand the teams they are supervising; it is designed to improve the performance of anorganization and the people working within it (Armstrong 1994; Torrington and Hall1998). Performance management is based on agreed objectives, competenciesrequired to undertake the work and development plans for achieving the objectives.Performance management focuses on strategically incressing the effectiveness of anorganization through improving the productivity of its people. According to Price (2000), Armstrong (1994), Amaratunga and Baldry (2002),Van der Bij Vissers (1999) and De Bruijn (2002), performance management systemsincorporate performance assessment or appraisal systems which are specificallydeveloped to appraise the performance of individuals or teams. Such appraisal requiresthe following: clearly defined organizational goals, individual or team objectives ormanagement targets, properly defined standards of performance and the skills and
competence required to meet them, regular formal review progress and systems offeedback and proposals for improvement. Armstrong (1994) says that the aims of performance management and humanresources management are similar, namely, to achieve sustained improvedperformance of organizations and employees to ensure that people develop andachieve their fullest capacity and potential for their own benefit and that of theorganization. Furthermore, performance management aims at creating an environmentwhich values people, empowering people in a way that latent potential can be realised,and to strengthen or change positively the organization’s culture.