CHAPTER – III:

REVIEW OF LITERATURE

 Reviews on Health Care

Industry
 Reviews on Nurses & their
Problems
 Reviews on Motivation
 Reviews on Factors
related to Research
 CHAPTER – III

REVIEW OF LITERATURE

Robert F. Hodgin et al2 in their study of 2010 concluded that ―We grouped the
statistically significant benefits from employment as pay, schedule flexibility, and
growth opportunity, and the statistically significant costs as travel time to work,
patient behavior, facility conditions, supervisor relations, and family needs. Our
categorization of the factors and the chi-square analysis correlates suggest that the
benefit and cost aspects are somehow weighed by each nurse in the decision to leave
the institution or to remain. We note with interest that five characteristics—gender,
education level, job title, State of West Virginia region, and facility size—showed no
significant correlation to any listed reason for the long-term-care nurses‘ separation
from their employer. We offer these findings as a step toward defining useful
variables to help explain long-term-care nurse turnover in more sophisticated
analyses, suggested by recent and relevant literature. Further work to affirm our
results, operationally define each dimension and determine the direction of causality
in well-structured models would aid the goal of addressing the long-term nursing

care needs of aging U.S. citizens and perhaps suggest policies to control the
institutional costs of long-term-care nurse turnover.‖
Vari M Drennan and Claire Goodman9 in their work of 2011 concluded that
‗The findings of this study demonstrate that recognition of the need to retain
experienced nurses as providers of patient care is not sufficient to embed striated
occupational roles such as nurse consultant within primary care and community
organizations. Nurse consultants were new roles that were superimposed on existing
services and as a consequence had to repeatedly negotiate and justify their role and
purpose. This was easier to achieve when nurse consultants addressed service
priorities that no other professional group believed was their responsibility. Models
of striated career advancement do not offer service providers the flexibility and
responsiveness that current reactive approaches to the development of nurse
clinicians do in the short term. However it is a wasteful approach that cannot be
sustained. The challenge for all health care systems is to address increasing demands
within available finances: clinical careers for nurses that ensure their expertise is
retained remunerated and shared with more junior staff is a key component of that.
This case example demonstrates how tantalizingly close the nurse consultant
initiative came in these settings to achieving that clinical career pathway but more
work was required to normalize clinician and managers‘ beliefs in the relevance and
need for the role. Those looking to embed these types of nursing workforce
innovations should pay due regard to these issues.

F. R. Gartner et al10 in their work of 2012 concluded that ―The Nurses Work
Functioning Questionnaire (NWFQ), a 50-item multidimensional measure of
impaired work functioning in nurses and allied health professionals due to CMDs,
was developed. Its seven subscales, with high-content validity and good internal
consistency, cover the full range of impaired work functioning of nurses and allied
health professionals with CMDs. The individual subscale scores give insight into the
precise aspects of impaired work functioning, allowing for tailoring of interventions
for individual needs. Therefore, the NWFQ demonstrates both breadth and depth of
measurement, while allowing for self-administration within a reasonable amount of
time.‖
T. Kankaanranta and P. Rissanen11 in their work of 2009 concluded that
―Although our results mostly confirm previous findings and theoretical hypotheses,
there are a few limitations as well. Our model was static by nature, not allowing any
lifecycle choices. Therefore, our results should be taken as the short-term response
of nurses‘ labor supply to the variables used in analysis. However, wage can also be
seen as an important factor in the long term, if it increases the number of new
entrants into nursing. Another limitation is that we employed cross-sectional data,
not allowing control for unobservable heterogeneity, such as factors related to
motivation. In addition, we report associations, not causal effects. However, our data
were rather rich and diversified, and did make it possible to thoroughly analyze, e.g.,
the effects of working conditions on labor supply. This study provides new evidence
for policy development by including detailed information about working practices
and employment characteristics, as well as behavioral aspects of nurses‘ choices in
labor markets. The most important finding from a labor market policy point of view
is that, even though wage elasticity was quite small, the effect on the hours supplied
was significant. However, wages alone may not sufficiently increase the labor supply

from the current stock of nurses; other elements, such as contractual conditions, seem
to play an important role as well. We also suggest that, e.g., possibilities for
professional development and promotion should be devised so that nurses can
expect to advance in their career. Although these factors do not fall within the scope
of this study, they will be analyzed in papers to come.‖
Nicholas G Castle12 in his work of 2006 concluded that Job satisfaction of
nursing home administrators (NHAs) has important implications for nursing home
staff, the nursing home industry, and quality of care. Other studies have shown
strong linkages between job satisfaction (dissatisfaction) and job performance and
turnover. The nursing home administrator job satisfaction questionnaire NHA-JSQ
could be used to examine similar relationships for administrators (i.e., job
(dis)satisfaction and job performance and turnover). Moreover, it is clear that NHAs
have a pivotal position in nursing homes. It is our hope that the NHA-JSQ be used,
first, to further show the importance of NHAs in improving nursing home care, and
second, to further improve the working conditions for NHAs themselves.‖
Trevor Murrells et al13 in their work of 2008 concluded that ―the impact of
time on job satisfaction in early career is highly dependent upon specific jobs, even
within the same profession. Adult, children's and mental health nurses work in
different contexts and settings, often with very different organizational cultures and
all of this may lead to a very different experience. Of course individuals choosing
these career paths may also differ in terms of characteristics and aspirations and
this also may influence the development of satisfaction. There is no single, simple
answer to the trend in job satisfaction over time. Future research should focus upon
understanding whether particular job characteristics could explain these findings
and should not simply explore satisfaction as a unitary construct when looking at
variation over time since contradictory findings emerge from different aspects
ofsatisfaction. Further research that investigates the benefits of a formal one year
preceptor ship or probationary period would also come in very useful.‖
Wen-Hsien Ho et al14 in their work of 2009 concluded that ―According to
the nurses' views, there are five major results in this study: (1) job rotation among
nurses could have an effect on their job satisfaction; (2) job rotation could have an
effect on organizational commitment; (3) job satisfaction could have a positive effect
on organizational commitment; (4) role stress among nurses could have a negative
effect on their job satisfaction; and (5) role stress could have a negative effect on
their organizational commitment.‖
Kethi Mullei et al15 in their work of 2010 concluded that ―The issue of
workforce shortage and mal-distribution is complex and not unique to the nursing
cadre or to Kenya. Poor infrastructure, limited training opportunities, high
workloads, inadequate supplies and supervision, undisclosed job locations for public
sector jobs, and most recently political instability all continue to be barriers to
successful rural recruitment and retention. Interestingly we found no suggestion that
those born in or with experience working in rural areas are more willing to seek rural
employment. While donor funded short-term contracts have increased recruitment in
recent years, it is possible that their impact will be compromised by their
unpopularity among nurses due to their lack of pension plans and job security. The
most popular proposed policy intervention among respondents was the provision of
additional financial incentives for rural posting, though these may be more effective
if implemented as part of a multi-dimensional package. Such a package would
require collaboration between economic and health policy-makers to earmark
funding to not only secure salaries but also improve working conditions. It should

also be accompanied by investment in information systems capable of monitoring

its impact with rigor.‖
 Deborah Hennessy et al16 in their work of 2006 concluded that ―The results of
this survey demonstrate that there is little difference in how different grades of
nurses perceive the nature of their role; in turn, this may reflect that in practice,
nurses have to discharge whatever care is needed, irrespective of limits of
competence. There is, then, clear need for specific job descriptions and competence
levels by grade of nurse. This study has also shown the distinction in training needs
by type of nurse and locality of work, which serves to demonstrate the importance of
collecting systematic data prior to developing post basic training packages.‖
Sara De Gieter et al17 in their work of 2006 concluded that ―This study
identified and categorized all rewards nurses receive for doing their job, starting
from the perceptions of the nurses themselves, instead of from the formalized
organizational reward systems or from the general reward literature. Indeed, the
results indicated that nurses value not only financial rewards, but also non-financial
and psychological rewards. Furthermore, rewarding potential and reward
preferences also seemed to differ according to age and seniority. When establishing
the most appropriate and cost-effective reward strategy, managers should therefore
not rely only on their limited number of formalized financial reward possibilities,
but should also acknowledge the value of non-financial and psychological rewards,
which can easily be more individualized and thus more effective in stimulating
nurses to perform to the best of their abilities.‖
Davood Hayati et al19 in their work of 2014 concluded that ―transformational
leaders transfer their enthusiasm and high power to their subordinates by the way of
modeling (Brief and Weiss, 2002). This manner can increase the power as a
component of work engagement in workers. Idealized influence among these leaders
can result in forming a specific belief among employees toward those leaders. Thus,
and as a result, the followers identify with the leaders and match themselves with
leaders‘ expectations and aspirations. So, leaders can easily transmit their
inspirational motivation to them. Consequently, it leads to make a positive vision by
which, and by setting high standards, challenges the employees and establishes zeal
along with optimism for attaining success in works.
 Nicholas G. Castle and John Engberg20 in their work of 2005 concluded that
―The 1-year turnover rates identified in this study were 98.6%, 66.8%, and 55.4%
for nurse aides, licensed practical nurses and registered nurses (NAs, LPNs and RNs)
respectively. This adds to a rather large body of research during the past 20 years
also showing high rates of staff turnover. Most importantly, we also show that very
low or very high levels of NA + LPN turnover are associated with lower quality of
care and that moderate to high levels of RN turnover are associated with lower
quality of care.

Majd Tawfeeq Mrayyan25 in his study of 2005 concluded that ―This study
provides evidence about the relationship between nurse job satisfaction and
retention. A descriptive design using survey methods was used in this study. A
convenience sample was obtained from public and private hospitals. Nurses
reported their job satisfaction to be at a moderate level and nurses were neutral in
reporting their retention. Nurses who work in private hospitals report higher levels
of job satisfaction and reported higher intention to stay at their jobs than nurses in
public hospitals. The findings emphasize the importance of promoting and
maintaining positive work milieu, which is an essential step in enhancing nurse job
satisfaction and retention for any health care organization. Nurse Managers must act
with supportive professional leadership to enhance the practice environment.

Heather K. Spence Laschinger et al27 in their work of 2009 concluded that

―The results suggest that working in environments that empower nurses to

practice according to professional standards and that also are free of uncivil
behaviors from supervisors and colleagues may protect them from burning out and
may promote retention in the nursing work settings. Given the current workforce
shortage in health care, every effort must be made to ensure that nurses are
exposed to high quality work environments that engage them with their work.
There are many anecdotal reports of workplace incivility in current fast paced
health care settings. Our results suggest that workplace incivility is related to health
professionals‘ experiences of burnout and important retention factors. Supervisor
incivility and burnout were particularly important determinants of turnover
intentions. The results further highlight the need to ensure that professional practice
environments foster high quality supervisory and collegial working relationships to
ensure that highly skilled nurses remain engaged in their work and that adequate
resources are in place for high quality patient care in today‘s chaotic health care
settings.‖
Claire Storey et al 28 in their work of 2009 concluded that ―Retention of
nurses, in particular older nurses, is dependent upon a number of distinct factors and
it is unlikely that the shortfalls will be resolved without a comprehensive approach.
The absence of policies specifically aimed at older nurses is a major barrier to
addressing the nursing shortage. Workforce development initiatives and the
contribution of nurses at both local and national levels are needed.‖
Barbara Molina Kooker and Cynthia Kamikawa 29 in their work of 2010
concluded that ―Analysis and management of the nursing workforce is clearly a
complex, dynamic process. It is disturbing that the demand for nursing care is

increasing while available nursing resources are decreasing. Driving patient and
nurse outcome data to the unit level, as with the Magnet Pilot Units and engagement
of nurse managers and staff, as with peer-to-peer accountability through the Nurse
Manager Council, has positively impacted patient and nurse outcomes. These
strategies contributed to building the Magnet culture. The development of current
staff nurses as clinical coaches contributed to decreasing turnover as well as
improving their communication skills when dealing with conflict or difficult
situations. Professional development of staff as new nurses, as coaches, or as nurse
managers is a worthwhile investment from the perspective of the Chief Nursing
Officer. The 56% reduction in nosocomial decubitus ulcer rate in the medical
intensive care unit, the 23% improvement in nurse retention and the 80% reduction
in vacancy rates have had a significant financial impact. Perhaps this impact is even
more significant while the organization is dealing with decreased reimbursements,
increased charity care and requirements to invest in high-cost technology to remain
competitive in the current economy.‖
Desiree Ritter30 in his work of 2011 concluded that ―The current literature and
evidence demonstrated a positive effect between healthy work environments and
the retention of nurses in the hospital setting. It confirmed the disadvantages and
often dangers of unhealthy work environments. The literature illustrated the
benefits of healthy work environments to the patient, nurse and the hospital. It also
discussed best practices related to healthy work environments. The importance of
Magnet recognition was addressed and the causal relationship to healthy work
environment was shown. Management as a key contributor was established.
Retention and the interlinking to a healthy work environment were studied.‖
Japie Greyling and Karel Stanz31 in their work of 2010 concluded that ―The
objective of this study was to investigate voluntary turnover among nursing

employees. It is clear from the research that this objective was met, as several
determinants were identified that indicate to nursing employers which staff
members are likely to terminate their employment. Nursing staff unanimously
indicated that the most important reason that they would leave is related to
unhappiness or discontent with their salary. It is therefore strongly suggested that
employers investigate their current reward and recognition policies and practices to
retain nursing staff. It is suggested that the hospital group should further investigate
ways of making the work environment more conducive to creating rapport between
management and nursing staff; more should be done within the workplace to create
an environment where there is a spirit of co-operation and teamwork. This notion is
supported by Jacobs (2005), in that employers can manage turnover by focusing on
contextual factors.‖
Ivica Glulasova et al32 in their study concluded that ―The respondents -
nurses - working on geriatric wards confirmed in their answers by 92% that they
have chosen to work with seniors during their studies. By the similar amount of
answers, the respondents commented the question of their motivation at work; they
have stated they are motivated especially by the feeling of a job well done. The
problem obviously rests on inadequate financial valuation as well as on insufficient
moral valuation by society. Nurses are worried about their legislative protection, the
loss of their occupation, the attitude of the patients in the way of increasing of their
claims disproportionately what often causes their physical and mental exhaustion.‖
Kate Shacklock and Yvonne Brunetto33 in their work of 2011 concluded that
―In the context of global nurse shortages, the results of this study give compelling
arguments for changes to healthcare policy and management. Key new knowledge
has been revealed which means that generation-specific interventions to extend
nurses‘ working lives are now feasible. Nurses find meaning and importance in their

work, and management and policy makers must ensure maximum exposure to
nursing work and give sufficient support to undertake the work properly. There are
important policy and management implications from these findings – repercussions
for healthcare management, nurse managers, nurse educators, human resource
managers and workforce planners, plus policy makers. If governments are serious
about trying to increase the retention of nurses in hospitals and to reduce nurse
shortages worldwide, then they need to capitalize on nurses‘ inherent attachment to
work, irrespective of generation.‖
Carol S. Brewer et al34 in their work of 2011 concluded that ―Turnover is an
inevitable outcome of employment over time that employers can influence but not
eliminate. The complexity of turnover problems means that there is no one solution
to decreasing turnover; multiple points of intervention exist. The results of this
study highlight the critical importance of satisfaction and organizational
commitment in forming registered nurses‘ (RN) intent to stay and give employers a
roadmap for improving their turnover rates. The fact that most RNs stay in hospital
employment indicates that hospital employers may be able to better determine RNs‘
needs and match them to their jobs. In addition, the finding that ‗shocks‘ such as
injuries influence turnover is important, because injuries can be avoided. Hospital
employers need to look carefully at methods that decrease injuries. As the continued
importance of satisfaction and organizational commitment in this and previous
studies have showed, attention to the fundamental concerns of nurses that increase
satisfaction and organizational commitment is likely to increase Newly Licensed
Registered Nurse‘s (NLRN) intent to stay as well and ultimately reduce turnover.
The goal for hospital employers should be to intervene before the intent to leave has
formed. Research to identify precursors of turnover that are not avoidable may help
to refine turnover models for NLRNs and allow more careful targeting of changes in
the work setting.
Matthew R. Carter & Ann E. Tourangeau 35 in their work of 2012 concluded
that ―One factor not addressed in this study as influencing nurse retention is
changing role opportunities for nurses. Internationally, economic pressures have
necessitated that employers examine and modify qualifications traditionally
required for nurse positions, with this sometimes resulting in the substitution of
nurses with less educated personnel. Alternatively, there is a concurrent expansion
in nurse role opportunities where nurses are assuming new roles and leading new
services. Role changes and new opportunities for nurses should be included in
future research on nurse retention. One of the major external factors influencing
turnover intentions of nursing staff is the prevailing economic environment. Given
the pressures facing the National Health Service (NHS) over the coming years and
the general uncertainty over the economic environment (e.g. would there be
another job to move to, even if they wanted to move), what may happen in the
future is that nurses stay put‘ despite not being satisfied, engaged or fulfilled etc.
with their jobs. Thus, the focus may need to be not only how to retain‘ nurses, but
more generally on how to promote satisfaction, engagement and fulfilment of nurses
working in a healthcare setting.‖
Jo-Ann V. Sawatzky and Carol L. Enns36 in their work of 2012 concluded that
―This research contributes to the current body of evidence related to the issue of
nursing retention. In addition, this study provides a voice for Emergency
Department (ED) nurses regarding the issues that are specific to their unique work
environment. The findings reveal key influencing and intermediary factors for ED
nursing retention and intention to leave. This research provides insight for nurse
managers to develop innovative, evidence-based strategies for the retention of nurses
in Manitoba‘s emergency departments. The insights gleaned from this research may
also be applicable to other areas of nursing in this province and beyond. Ultimately,

addressing the issue of nursing retention will benefit the health-care system by
having a favorable impact on economic, patient and nursing outcomes.‖
Nebiat Negussie37 in his study of 2012 concluded that 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. 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.‖
Mohd Sobri Minai and Yasser Mansour Almansour38 in their work of 2013
concluded that ―Insight shows that the motivation factors influencing the satisfaction
of the nurses include all the hypothesized factors except the factors of (i) support
from peers on their nursing decision, (ii) working relationship with their peers, (iii)
support from physicians for their nursing decisions and (iv)the time required for
completing the indirect patient care. Factor three and four are most critical that
require urgent attention to enhancing the satisfaction and motivation of the nurses.
For the hygiene factors, besides the findings on the positive impact on the nurses job
satisfaction, the nurses are found not to be satisfied with (i) the working hours
pattern, (ii) direction on the departmental high level of clinical competence, (iii)
satisfaction on salary (iv) adequate funding for health care premiums and (v)
intellectual environment stimulation. Factors three to five are most critical to be
given attention as these factors are claimed as not being provided to them. The study as
revealed the factors impacting on the nurses in the environment dominated bymale
nurses and identifies the factors relating to motivation and hygiene factors contributing
to the nurses‘ motivation. In this paper, the factors are listed according to their
importance and shall provide crucial insight into the important factors contributing to
the nurse job satisfaction.‖
Gisele Mbemba et al39in their work of 2013 concluded that ―This umbrella
review reveals that financial incentives, supportive relationships in nursing
(mentoring, clinical, supervision and preceptoring), Information and
communication technologies (ICT) support and the career pathways for rural health
constitute potential strategies that could influence the retention of nurses in rural
and remote areas. Even though the impact of financial interventions is supported by
two reviews, most of the studies included in these reviews are from the USA, making
the results less applicable to countries with a different healthcare system such as
Australia and Canada, or to low- and middle-income countries. In order to maximize
the use of retention funding for the purpose of minimizing avoidable turnover,
Buykx and colleagues suggest using a framework that addresses known
determinants of poor retention which could support resource allocation decisions
based on scientific evidence. Retention funding should also be seen as an ingredient
of a comprehensive retention strategy developed on the basis of local needs. Finally,
Buykx and colleagues suggest that the impact of strategies on subsequent workforce
retention should be assessed using rigorous evaluation methods. Given the limited
empirical evidence available on effective retention strategies for rural and remote
nurses, we also encourage more research on the main determinants of nursing
retention in rural and remote areas that could inform future strategies.‖
Fadi El-Jardali et al40 in their study of 2013 concluded that ―Study findings
reflect a generally unstable and dissatisfied nursing workforce in rural and
underserved areas in Lebanon. Such findings are disquieting to nursing planners,

policy and decision makers as they cast a doubt on the sustainability and equity of
providing health services to rural populations. Nevertheless, the study identifies
multiple opportunities for intervention in order to rectify the situation and enhance
the satisfaction and retention of the rural nursing workforce, with particular
attention to the work setting. Our findings highlight that the nursing workforce is
not homogeneous, and nurses may want different things at different life stages and
in different settings. Primary healthcare, often seen as the poorer and less desirable
cousin of the higher status hospital sector, comes out rather well in this survey. The
less demanding nature of the job in this sector meant that it was better able to
retain nurses despite the relatively poor amenities. The issue of how hospitals in
those underserved areas can create a contented workforce that is willing to commit
to the longer term seems to be a much greater challenge. Stakeholders are urged to
work collaboratively to devise strategies and initiatives that would bolster the
retention of nurses in underserved areas; especially younger nurses and those
working in the hospital. Such strategies would help enhance access, quality and
equity of care delivered in rural settings and would contribute to improving the
retention of the healthcare system‘s most valuable asset… nurses.‖
Kalandyk H and Penar-Zadarko B.found41 in their work of 2013 concluded
that ―The low pay was considered as a main aspect of dissatisfaction in nursing,
while financial security resulted in a feeling of satisfaction. Professional problems of
the respondents correlated with health problems, job stress, experiencing tension,
reduced motivation to work, an increase distance to the employees, and a feeling of
dissatisfaction and frustration with the work. Age of respondents differentiates their
health problems – the older people often were accompanied by disease of the spine,
and the younger had allergies to disinfectants. The respondents were exposed to
various forms of violence in the workplace, including raised voice, bad language,
insulting, undermining nursing skills, spitting, pushing or beating.

Sheri P. Palmer42 in his work of 2014 concluded that ―Nursing turnover is a

challenge in many hospitals worldwide, as well as in Guayaquil, Ecuador. This study
was successful in identifying many issues relating to nurse satisfaction among the
employees of this hospital. These issues may influence nurses to leave or stay in their
job. Hospital and nursing administration can work together to implement strategies
to increase nurse satisfaction, which may help in nursing retention. Although an
increased budget for wages would seem to be the cure for nurse turnover, there are
other practical actions that can be investigated and utilized.‖
Valda Upenieks43 in their work of 2003 concluded that ―Magnet hospital
features have been associated with lower turnover and higher levels of job
satisfaction. These key organizational characteristics include such elements as
decentralized organizational structures, emphasis on participatory management,
value of professional nursing practice, and systematic communication between
clinical nurses and leadership. Nurse involvement in decision making has been
reported as the most significant variable explaining job satisfaction (Gleason-Scott
et al., 1999). Magnet organizations have enabled professional nurses to be
autonomous and empowered and to do for patients what they know should be done
in a manner consistent with professional standards (Sullivan-Havens & Aiken,
1999). This philosophy of nursing excellence is crucial for attracting and retaining
clinical nurses, as well as vital for enhancing job satisfaction and longevity -- a key
strategy in surviving the nursing shortage. The national health care system is facing
another significant nursing shortage, particularly in the acute inpatient setting. The
belief has been that increasing nurses' salaries will attract more individuals to the
profession. However, higher wages alone will not be a powerful enough magnet to
retain the excellent nurses presently practicing. Nurses want to be appreciated and
respected, and they want to take responsibility in the decision-making processes
concerning

patient care. One model that supports these claims and that has empirically
demonstrated lower turnover rates of nurses is the "magnet hospital" model. The
purpose of this study is to present a prevention model that can assist nurse
executives in attracting and retaining nurses in the acute hospital setting. The model
refers to the prevalence of the nursing shortage problem, the risk factors involved,
and the underlying causes. The model also focuses on the supply side of the nursing
shortage and provides recommendations on how best to increase the nursing
supply.‖
Pratyay Pratim Datta and Debalina Datta44 in their work of 2013
concluded that ―For an organizational output its employees‘ satisfaction as well as
motivation to do work is the main key factors. It is well known that motivated
employees improve the productivity of any organization which ultimately helps the
organization in reaching its goal. Overall the front office staffs were more satisfied
as employees in the organizations. The management authority should pay sufficient
attention to improve the productivity of the organizations by arranging regular
meeting with the employees and fulfilling their needs.‖
Shivangee Singh and Pankaj Kant Dixit45 in their work of 2011 concluded
that ―Employees comprise the most vital assets of the company. In a work place
where employees are not able to use their full potential and not heard and valued,
they are likely to leave because of stress and frustration. They need transparent
work environment to work in. In a transparent environment where employees get a
sense of achievement and belongingness, where they can best utilize their potential
and realize their skills. They love to be the essential part of such organization and
the company is benefited with a stronger, reliable work-force harboring bright new
ideas for its growth.

Persefoni Lambrou et al46 in their study of 2010 concluded that ―this study
showed that motivation was influenced by both financial and non-financial
incentives. The main motivating factors for the health workers in this public hospital
sample were appreciation by managers and colleagues, a stable job/income and
training. The main discouraging factors were related to low salaries and difficult
working conditions. Activities associated with appreciation such as performance
management are currently not optimally implemented, as health workers perceive
supervision as control, selection for training as unclear and unequal and performance
measurement as not useful. The kind of non-financial incentives identified should be
taken into consideration when developing human resource management strategies.
The knowledge of motivation factors and factors leading to increased job satisfaction
allow the implementation of targeted strategies of continuous improvement.‖
Kelli Burton47 in his study of 2012 concluded that ―Motivation is a complex
concept and can help or harm an organization depending on how it is used within an
organization. If a manager takes the time to understand the needs of his/her
employees, then the recognition can be extremely useful. There have been many
philosophers, who have tried to understand what motivates people, but every person
is different and a theory cannot describe all people. It is understandable the mangers
have a full time job and do not have much down time to be spending on rewards, but
it also gives them the opportunity to understand their employees and connect with
them on a personal level. Managers are not the only ones who can recognize others
in the workplace. Employees can recognize each other as well. It has been proven to
that one can not directly motivate someone else, but they can give them the tools
they need to motivate themselves. Managers are the resources for employees and
they should make sure that their work environment is pleasant and desirable. This
will help the productivity and improvement of their employees. If the above
suggestions are implemented properly, managers will have a fully motivated team.‖

M.A.T. Matsie48 in his thesis of 2008 concluded that ―Health sector policy
makers and health facility managers must recognize the importance of work
motivation in reaching sector and organization goals, and they must understand the
links between their current policies and worker motivation. The results suggested
that improving motivation to perform well will require multiple interventions.
Hence it is very important to ensure that different motivational strategies are in
place and implemented correctly. In a hospital set-up it is important that employees
are motivated as their performance affects the wellbeing of patients and the
community in which they operate. The researcher concludes that different external
motivators (motivational factors) should be used simultaneously to stimulate
employees' motivation as different employees and people in general are motivated
by different things. For example, other people are motivated by money (market
related salaries, performance bonuses, overtime payments); others by a conducive
working environment (good supportive relationship with managers, supervisors
and colleagues and also by promotional possibilities); others by growth and
learning opportunities (training); while others are motivated from within
themselves, self- driven and take responsibility for themselves and their
performance (internal locus of control). Others are motivated and credit others for
their success or failures (external locus of control) which all have an impact on the
way they perform their duties and to the overall productivity of the company.‖
Sebahattin TAŞ et al49 in their work of 2012 concluded that ―It is seen in the
medical institutions that hospital administrations apply to tools such as course,
seminar, social activities and appreciating but these are not considered sufficient by
employees. However this case brings the wage rise expectation, when considering
people who say ―I prefer having a high title to having a job of higher salary‖ form the

majority, it is seen that the idea that activities done for increasing motivation is
insufficient is not only because of the low level of gaining wage rise reward. It is
obvious that the gaining earthly reward of the medical institution employees while
doing their job is important for motivation but also that they will not work harder
just to gain earthly reward. This case shows that the sense of belonging to their
professions and workplaces is great. The case that people who have worked more
than one hospital say that the current hospital administration is more eager to
increase motivation can be explained in that hospital administrations give more
importance to motivation activities as a matter of policy as time goes by. However, as
reflected in the answers, these studies have not reached the sufficient level yet.