AuthorStefan, Simona Catalina
  1. Introduction

    Nowadays, the healthcare sector is facing stiff competition and increasing needs and expectations from the patients (Hee and Kamaludin, 2016). To meet these challenges, healthcare organizations must develop and expand continuously to be able to provide high quality health care as their ultimate objective. Health sector policy makers and health facilities managers must recognize the importance of work motivation in reaching sector and organizational goals, and they must understand the links between their current policies and worker motivation (Van Lerberghe et al., 2002).

    Health workers' motivation can potentially impact the health services delivery (Mbilinyi, Daniel and Lie, 2011) and it is therefore important to make workforce development one of the priorities of health policy and consider it an essential public health function (Dussault and Dubois, 2003). The motivation of healthcare workers will undoubtedly reflect in their performance and, of course, in job satisfaction, which in turn impacts the quality of health services, their equity, efficiency, efficacy, accessibility and viability (Bennet and Franco, 2000; Dussault and Dubois, 2003).

    However, despite the increased attention grounded in motivation and its individual and organizational implications, there are still some underling aspects which are not well understood, one of the reasons being the lack of an appropriate instrument for measuring motivation (Borghi et al., 2018; Lohmann et al., 2017). Even if motivation and job satisfaction have been both mentioned as critical determinants of health workers performance and retention, they are abstract concepts which cannot be directly measured (Mbindyo et al., 2009).

    Moreover, although there are studies suggesting clear links between motivation and job performance (Alhassan et al., 2016; Grant, 2008; Kuvaas, 2006; Sato et al., 2017), other studies which established a relationship between job satisfaction and job performance (Petty, McGee and Cavender, 1984), and others which indicated a relationship between motivation and job satisfaction (Oguz et al., 2016), a clear connection between all the three terms mentioned above was not yet found.

    This study aims to investigate the motivation level of employees in the Romanian healthcare system, based on the five levels of motivation, according to the Maslow's hierarchy of needs (1943): physiological needs, safety, love and belonging, esteem and self-actualization. The study also attempts to evaluate the impact of satisfying each of these needs on performance and job satisfaction. The novelty and relevance of the paper stem from the creation of a model that highlights the intimate mechanism explaining the relationship motivation-satisfaction-performance and providing empirical evidences to support it. The paper also offers a new perspective on the motivation-performance relationship, taking into account every basic human need described by the Maslow hierarchy, and assumes that the relationship between each dimension of motivation and performance is mediated by professional satisfaction. At the same time, the novelty of the paper is also supported by the study of the above described relations within a domain with distinct features, that of health services, which is also considered to be of major interest.

    Based on the review of the relevant literature (section 2), a conceptual model and five research hypotheses were developed. The methodological section (3) provides the overall study design, research instrument and the main methods of data analysis. The main results, which include also the validation of research hypotheses, are comprehensively presented and discussed in section 4 of the paper. In the conclusions part, limitations and future lines of research are outlined.

  2. Literature review

    Motivation is a process that influences and directs behavior in order to satisfy a need. Maslow (1943) developed a theory of how all dimensions of motivation are interrelated, based on the idea that human behavior is determined by a limited number of developing fundamental needs which emerge and operate in a sequential order (Sengupta, 2011). He called his theory a 'need hierarchy'. Maslow's hierarchy of needs consists of five levels/dimensions of motivation: physiological needs, safety, love and belonging, esteem and need for self-actualization. When a lower level need is met or overtaken by a higher level one, people tend to be no longer motivated by satisfying that need (Suyono and Mudjanarko, 2017). Furthermore, people will try to meet the needs of the next level. Maslow's theoretical tenet indicate that it is necessary for prepotent needs to be satisfied before the next level need emerges and the person becomes concerned by satisfying it (Taormina and Gao, 2013).

    Maslow's model was studied in various disciplines: in social sciences, psychology, sociology and education (including adult learning) and was used as a model to understand the individuals' needs, while in business it was approached as a model to explain employees' motivation (Benson and Dundis, 2003). Since it was first formulated, Maslow's theory was further developed by Maslow itself or by other researchers--i.e. Alderfer (1969) ERG theory. The theory was also subjected to empirical testing and criticism (Berl, Williamson and Powell, 1984; Hall and Nougaim, 1968; Lawler III and Suttle, 1972; Soper, Milford and Rosenthal, 1995) that contested its empirical basis and applicability within an organizational context. In sum, Maslow's theory highly influenced the way of thinking and subsequent research (Alderfer, 1969) and became the most well-known theory that attempted to explain the mechanisms of human motivation.

    Human resources motivation is primordial in all sectors of activity, especially in the healthcare system, where the need for high quality services is in a continuous grow, because it has become an essential condition in creating and maintaining high performance, both in terms of each employee and overall organizational performance. In the healthcare system, motivational factors can be differentiated into many categories. For instance, in a study conducted in Pakistan, motivating factors were intrinsic and social cultural factors, like serving people, respect and career growth were also important (Malik et al., 2010).

    As it is stated by Daft (2010) motivation can lead to behaviors reflecting high performance within an organization, therefore, it is the manager's responsibility to design the right combination of motivational tools and incentives able to simultaneously satisfy employees need and encourage high performance. In terms of job performance, in most hospitals are used various performance evaluation methods as a means of monitoring and evaluating the individual and organizational objectives. Motivation is considered a strong predictor to job performance (Hee and Kamaludin, 2016, p. 343).

    Previous studies addressed the issues of motivation-performance relationship, providing theoretical and empirical arguments to support a positive influence of motivation on professional performance. Studies suggested both a direct effect (Alhassan et al., 2016; Sato et al., 2017), but also a mediating role of motivation for other determinant factors of performance (Deci, Olafsen and Ryan, 2017; Rowe et al., 2005; Taghipour and Dejban, 2013).

    The results of several studies indicate a correlation between motivation and job performance (Grant, 2008; Van Knippenberg, 2000). Other studies further demonstrated that employees with higher levels of motivation potentially have better professional performance (Kuvaas, 2006). Looking at the connection between motivation and performance, one may see that it is a relationship of mutual conditioning since, when the individual expectations and organizational demands overlap, there are high chances of fostering professional performance. Therefore, in the work process, motivation is the driving factor of performance and links the individual and organizational interests (Gilmeanu, 2015, p. 70). Taghipour and Dejban (2013) state that employees' motivation is one of the most effective managers' strategies to enhance effective workers job performance within their organizations.

    Job satisfaction should be considered an important factor in healthcare settings. Atefi et al., (2014) identified three main factors influencing nurses' job satisfaction: (1) work environment factors (benefit and rewards, working conditions, team cohesion, available medical resources, responsibilities, patient and doctor perceptions, leadership skills), (2) spiritual feeling (involvement in patient care and help giving), and (3) motivation (task requirement, clinical autonomy and professional development).

    Even motivation and job satisfaction are two independent concepts, they are also interrelated to each other (Oguz et al., 2016), involving cognitive, affective, and behavioral processes (Mutale et al., 2013). Thus, Oguz et al (2016) reported a strong positive correlation between job satisfaction levels, motivation and organizational commitment of healthcare professionals who work in the public healthcare sector in Turkey. As a result of the analysis, it was found that both job satisfaction and motivation had a significant effect on organizational commitment. These two factors can significantly influence labor productivity, labor fluctuation or absenteeism, or in a word, performance (Lefter et al., 2012, p. 129).

    There are also strong empirical evidences supporting a causal relationship between job satisfaction, quality of health care and patient safety (Alhassan et al., 2013; Berenson and Rice, 2015). In the healthcare system, the job satisfaction of physicians is in the interest of the entire healthcare context (DeVoe et al., 2002) and has important effects on physician productivity, the quality of medical care, and the supply of physicians available to meet the medical care...

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