What Motivates Change within a Healthcare Organization?

Change within a healthcare organization is a challenge. In order to establish effective and long-lasting change, an organization’s stakeholders will need to be motivated to accept these changes. To better understand how an individual is motivated, this mini review will discuss existing motivational theories, including theories on content and process motivation, and relating them to organizational change.


Introduction
Initiating and sustaining effective change within a healthcare organization is a daunting challenge. Some research has indicated failure rates of one-third to two-thirds of major change initiatives [1,2]. While others have reported failure rates as high at 80% to 90% [2]. Changes within an organization is dependent on multiple factors, including effective leadership and motivation of the stakeholders. According to Rogers accepting changes can occur in stages from the initial awareness of the change, interest in the change, a trial period, decision to continue or quit and full adoption of the change [3]. Furthermore, there are five categories of individuals that have been identified on the basis of the general acceptance of change: the early adopters, the early majority, the late majority and the laggards [3]. To initiate an organizational change, ideally managers in leadership positions will aim to motivate stakeholders to become early adopters of the proposed change. Thus, understanding an individual's motivation to accept and implement change is crucial towards successfully establishing long-term change.

Content Motivational Theories
Motivation can be defined as the influence or drive that causes an individual to achieve a certain goal [2,4]. Within organizational behaviour, motivational theories can be categorized within two groups: content and process theories. Attempting to understand how an individual is motivated through these theories can provide insight into how an individual may be driven towards achieving their goals or the goals of an organization. The content approach to motivational theories in organizational behaviour focuses on the assumption that individuals are motivated by their desire to satisfy an underlying need. Content theories include: Maslow's hierarchy of needs, Herzberg's two-factor theory, and McClelland's needs theory. Each will be reviewed briefly in the context of healthcare professionals within an organization.
Maslow's hierarchy of needs is a theory that assumes that individuals will want to achieve their needs, which are, in turn, prioritized by importance. In Maslow's theory, there are Further in the hierarchy, there will be a desire to achieve their "esteem needs" both extrinsically (i.e. individuals will have to seek the approval of their peers and their supervisors) and intrinsically (i.e. individuals will seek to accomplish goals for their own selfesteem). When applied to healthcare professionals, it can be construed that a healthcare worker will be motivated to perform their job effectively and provide safe the best patient care, thus their esteem needs are satisfied when they are recognized for their patient care (extrinsic esteem need) which in turn provide them with self-respect and self-esteem (intrinsic esteem needs).
While it is important to understand what motivates individuals, each individual will be motivated by different factors. In Alderfer's ERG theory, there is an alternative approach to needs hierarchy.
In this theory, there are three categories of needs; 1) Existence (basic material and physiological requirements), 2) Relatedness (need to develop and sustain interpersonal relationships) and 3)

Growth (individuals intrinsic need towards personal development).
In Alderfer's theory, individuals may seek satisfaction of either higher or lower-level needs in a non-linear pattern [7]. It also addresses that individual may have several needs that need to be satisfied, thus motivation would need to focus on several factors.
Using Alderfer's theory, an individual may be motivated to accept an organizational change, as long as the majority does so (relatedness), while also being motivated at the growth level, as acceptance of this change will have the potential to improve patient care.
In Herzberg's two-factor theory, otherwise known as the motivator-hygiene theory, it was noted that there are five motivating features of work that determine satisfaction, namely, 1) Achievement, 2) Recognition, 3) the job itself, 4) Responsibility, and 5) Advancement [4,8]. In contrast, demoralizing factors were noted as, 1) institutional politics, 2) management approach, 3) supervision pay, 4) poor work relationships and 5) poor working conditions [8]. Attention to these motivating factors is crucial. By recognizing the achievements of healthcare workers, and supporting their performance, there will be improved job satisfaction and accepting the organizational change. Additionally, by addressing the demotivating (or hygiene) factors, such as poor infrastructure and resources, the risk of not accepting the organizational change is minimized.
McClelland's needs achievement theory postulates that individuals are driven to success through seeking "personal achievement rather than rewards themselves" [4,8]. McClelland identified three types of motivational needs: 1) achievement, 2) power, and 3) affiliation [7]. Individuals may be strongly achievement-motivated and are both intrinsically motivated "to do their best", as well as extrinsically motivated by valuing feedback on their work. High achievers will tend to work harder and more efficiently, and effect positive outcomes within an organization.
Most healthcare professionals would be categorized as those motivated by achievement. Healthcare professionals will often cite intrinsic motivators, such as a "strong sense of calling" and "doing their best", for their clinical commitment and patient care [9]. Thus, proposing a change within an organization that would improve their care of patients would motivate health professional's achievement goals.

Process Motivational Theories
In addition to the content motivational theories, process theories can also assist in predicting an individual's behaviour.
Process theories include: 1) Expectancy theory, 2) Equity theory and 3) Satisfaction-Performance Theory [7]. Expectancy theory suggests that an individual's level of motivation will vary with respect to their desire for an specific outcome and their perception on how their performance effort will achieve this outcome. There are three factors that will influence the motivation of the individual, including 1) valence (the strength of an individual's desire for a specific outcome), 2) instrumentality (the perception an individual that relating performance and outcome) and 3) expectancy (the perception that an individual's effort will positively influence the outcome) [7]. Managers may find this theory useful in understanding how individuals are motivated to perform. The assumption is that the costs and benefits of the task and outcomes will be weighed by the individual. Likewise, indifference towards an outcome will also result an individual's lack of motivation.
Equity theory assumes that an individual will be motivated to perform, based on their perception of their inputs (i.e. their contributions) and the outputs (i.e. recognition of their contributions). There are factors that may influence individuals to perceive an inequity. These include 1) altered inputs (reduced productivity), 2) altered outcomes (pay increase, recognition), 3) cognitive distortions of inputs/outputs (self-esteem distortions), 4) leaving the field, 5) cognitive distortions of inputs/outputs of others, 6) changed comparison order [7]. Understanding the equity accomplishment) and extrinsic motivators (i.e. recognition of performance) will lead them towards higher performance. In the case of accepting an organizational change, focusing on an individual's motivation to provide the best patient care and receive recognition of their efforts, would lead towards effective change.

Conclusion
Ultimately, there is no single content or process theory that would explain how an individual is motivated to perform. Rather, it can be assumed that depending on the context of the organizational behaviour there are aspects from each of these theories influencing an individual. Healthcare workers are intrinsically motivated to perform their best and provide optimal patient care, while also being extrinsically motivated through recognition of their achievements and providing advancement opportunities, thus incorporating aspects of Maslow's, Alderfer's, McClelland theories, as well as Equity and Satisfaction-Performance theories. By presenting a change within a healthcare organization, as an opportunity to improve patient care, improve clinical workflow and reduce medical errors, leaders can address these intrinsic motivators of healthcare professionals. Likewise, by providing work recognition and support during their training process, extrinsic motivation will also be addressed. Thus, management in leadership will need to address an individual's motivating factors in order to establish long-standing change.