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Motivation Chapter Objectives After reading this chapter, you should be able to 1. Describe the basic natures of motivation and motivational processes in healthcare. 2. Apply need-based approaches to the motivation of healthcare employees. 3. Feature the elements of operant models of learning and motivation in healthcare settings. 4. Use ideas from cognitive models of motivation in the healthcare environment. 12 © Wavebreak Media/Thinkstock The Nature of Motivation Chapter 12 One of the more elusive terms featured in management and organizational behavior is motivation . Any cursory examination of the textbooks written in these fields would reveal rela - tively disparate views of what the word means. To complicate matters, explaining motives and motivation in healthcare settings may be even more difficult. Individual professions align with a series of motives, ranging from “making a good living” to “helping humanity.” Seeking to match a person’s degree or level of motivation with tangible outcomes may be impos - sible. A doctor and nurse, along with the hospital staff, may work diligently to help a patient understand that he must stop an unhealthy habit, such as smoking, in order to recover from an ailment; yet the patient may be unwilling to do so and could die as a result. In this case, even though the staff may have been highly motivated, the outcome does not provide evidence of that level of motivation or effort.

Even in such a confusing environment, however, healthcare managers need to understand and apply motivational principles as part of their responsibilities. This chapter explores the basic nature of motivation. The sections that follow evaluate the three major categories of motivation theories as they apply to healthcare management.

12 .1 The Nature of Motivation One approach to defining motivation is to consider it as it specifically applies to a workplace set - ting. In this situation, one may think of motivation in terms of a result, or behavior. Using that reasoning, Jones (1955) defined motivation as something that starts behaviors, maintains behav - iors, or stops behaviors. Table 12.1 identifies examples of healthcare workplace behaviors worthy of being started and maintained, as well as those that are best when stopped.

When using a definition of motivation based on behaviors, the question becomes, “What factors motivate healthcare employ - ees, and how can healthcare managers deploy those factors to motivate them?” To achieve the outcomes displayed in Table 12.1, various motivational theories may be applied. In 1975, Szilagyi and Wallace conceptualized motivation into two cat - egories: content and process. Content theories of motivation examine factors within individuals—notably, needs—that lead to behaviors. Content theories describe the essence or content of motives, which take the form of unsatisfied or unfulfilled needs as the factors that motivate employees.

Process theories examine the progression of events that lead to motivated or unmotivated behaviors—or, in other words, how to motivate employees. Process theories subdivide into two different sets: operant processes and cognitive processes.

Operant process theories of motivation explore external factors that increase and decrease behaviors using Skinner’s behaviorism principles (Skinner, 1953, 1974a) . Cognitive process theories of motivation exam - ine the thought processes or mental reasoning processes that lead to behaviors. Table 12.2 pre - sents the categories of motivation and theories present in each category. The sections that follow discuss each theory type in more detail. © Ryan McVay/Digital Vision/Thinkstock ▲ ▲ What might motivate physicians in the care of their patients? The Nature of Motivation Chapter 12 Table 12.1 Behaviors at work in healthcare organizations Start and maintainStopExamples of workplace behaviors Attendance AbsenteeismCovering shifts Punctuality TardinessArriving when scheduled Sanitary protocols Unsanitary habitsHand washing or sanitizer use Safe work practices Unsafe work practicesUsing gloves or radiation protection Productivity/effort Lack of effortMaking rounds Changing bandages Providing follow-up care Paying attention to patient needs Cooperation with others ConflictsMaintaining relations with patients, families, and other care employees Citizenship behaviors Poor citizenshipCleaning up work station Helping others Informing others of unusual incidents or treatment outcomes Ethical actions Unethical actionsMaintaining confidentiality Avoiding workplace gossip Healthy habits Unhealthy habitsIncentivizing smoking cessation and reduction of alcohol consumption Providing access to substance abuse programs Table 12.2 Categories of motivation theories Theory typeExample theories Content Maslow’s hierarchy of needs Alderfer’s existence, relatedness, and growth (ERG) theory McClelland’s needs theory Herzberg’s two-factor theory Operant Reinforcement theory Organizational behavior modification (OB Mod) Cognitive Equity theory Expectancy theory Content Theories of Motivation Chapter 12 12 . 2 Content Theories of Motivation Content, or need-based, theories of motivation were among the first to appear in management literature. Their appeal rests in the notion that nearly anyone can express a list of needs; thus, the motivations associated with those needs should be identifiable. Organizing various needs into theories that explain motivational processes as progressions, or categories, of needs would appear to be a logical method. Four content theories of motivation that were developed in the mid-1900s apply to healthcare management.

Maslow’s Hierarchy of Needs Abraham Maslow (1954) created one of the first need-based theories of motivation. The hierarchy of needs approach can be described as a satisfaction–progression model. In essence, an individual regularly experiences a need until that need is regularly satisfied. At that point, the person “pro - gresses,” or moves toward the next need level. As shown in Figure 12.1, an individual moves from the lowest level need set (physiological) to the highest order need (self-actualization). Table 12.3 demonstrates how this progression might play out in a healthcare setting.

Self-actualization consists of two elements: one’s life work is helpful or meaningful to other peo - ple, and the work fulfills personal needs for growth, achieving one’s potential, and being true to oneself. A self-actualized person performs work that he or she wishes to do, and the work helps other people. Many healthcare jobs include highly self-actualizing aspects, because it is a “help - ing” profession.

Figure 12.1 Work and Maslow’s pyramid f12.01_HCA340.ai Needs Application at work Meaningful work that expresses the inner self of the employee (At all levels) Needs for knowledge and beauty Promotions, contests, high performance evaluations Friends at work Met through job security (union protection, tenure, etc.) Met by having a job Self-actualization Esteem Belongingness and love Safety and security Physiological needs Source: Hall & Nougaim, 1968. Copyright © 1968, Elsevier. Content Theories of Motivation Chapter 12 Table 12.3 Maslow’s hierarchy and healthcare Hierarchy levelHealthcare application Physiological Having a job in a healthcare setting that provides for basic needs Safety Job security Safety from violence and infectious outbreaks Belongingness Friends in the healthcare organization Esteem Certifications Privileges granted Awards for performance Self-actualization Meaningful work Expressing personal preferences Maslow considered physiological and safety needs to be lower-order, physically based needs. Social needs, esteem, and self- actualization constitute higher-order needs that have a psychological or mental basis.

Maslow surmised that relatively few people achieve self-actualization status.

Empirical research fails to support the hierarchy of needs model (Lawler & Suttle, 1972). Problems associated with theory include the following:

• It does not explain the degree of satisfaction needed to progress to the next level.

• It fails to account for individuals who experience the five needs in a different order.

• It does not recognize other key needs, such as the need for power.

• It cannot predict the type of behavior associated with any given need.

However, the hierarchy of needs theory did lead to the development of other content theories and eventually to newer conceptualizations of the nature of motivation.

Alderfer’s ERG Theory Clayton Alderfer (1972) sought to simplify Maslow’s hierarchy of needs by breaking it down into three concepts: existence, relatedness, and growth. The progression in his ERG model is: Existence → Relatedness → Growth © Digital Vision/Thinkstock ▲ ▲ Relatedness, or social needs, is part of both Maslow’s hierar - chy and Alderfer’s ERG theory. Content Theories of Motivation Chapter 12 Existence needs are comparable to the concepts of physiological and safety needs. Relatedness matches social needs. Growth needs reflect esteem and self-actualization. Notice that existence needs could be considered as physical in nature, relatedness as social in nature, and growth as psychological needs. Thus, the progression is also: Physical → Social → Psychological Alderfer added a second concept to Maslow’s approach—frustration–regression. If, for example, a worker’s physical needs have been met but he or she is socially unskilled, then that employee will become frustrated by the inability to make friends. Such a person would then “regress” back to the existence level and feel that need more strongly. The individual might then become obsessed with possessions and other physical objects. Likewise, an employee with routinely satisfied physi - cal and social needs who is working in a dead-end job would be unable to fulfill growth needs.

That worker might greatly expand his or her social network as a response to the frustration.

Although the ERG model does add to the ideas in the hierarchy of needs, it does not solve any of the problems associated with that theory. As a result, other need-fulfillment models were soon developed.

McClelland’s Need Theory David McClelland (1961) identified a series of needs not addressed by Maslow and others. Of these needs, three have been associated with management and organizational behavior and seem particularly relevant in healthcare settings. He identified needs for achievement, power, and affil - iation, which all relate to many on-the-job issues in physician’s offices, hospitals, pharmaceutical company sales positions, medical equipment supplier organizations, medical suppliers, and other settings.

The need for achievement reflects the degree to which an individual exhibits the drive to excel and generate accomplishments. Finishing medical school and opening a medical practice indicate a high need for achievement. The same holds true for many vocations in the healthcare indus - try, such as a person with a degree in pharmacology who opens a drug store with a pharmacy.

Individuals with high needs for achievement tend to take moderate levels of risk. Risks taken are connected to the person’s confidence that he or she can complete the task.

High achievers prefer immediate feedback, value accomplishment as much as they do money and material rewards, tend to become preoccupied with the task at hand, and are more likely to become entrepreneurs. High achievers are also more likely to succeed in circumstances in which they can direct activities and are personally responsible for outcomes. As managers, they may be less helpful to employees, concentrating instead on their own projects. High achievers are also prone to stress-related problems. Low achievers are inclined to create self-fulfilling prophecies of failure. They lack confidence and avoid challenges. Some evidence suggests that the need for achievement can be taught or enhanced (McClelland, 1965).

The need for power suggests the drive of an individual to make others behave in ways they would not otherwise choose. When properly channeled, the need for power can be related to manage- rial success in some healthcare organizations, as it helps administrators and other managers accomplish various tasks in a timely fashion. To do so, however, their power cannot be created or used in the pursuit of personal goals, and they should not place influence ahead of effective performance (Kipnis, 1974). Content Theories of Motivation Chapter 12 The need for affiliation reveals a need for close interpersonal relationships, including joining groups and seeking love or friendship. High needs for affiliation can be a detriment to becoming a successful manager, because the individual may worry too much about the opinions and percep - tions of others (Winter, 2001). People with high needs for affiliation should be placed in jobs with greater degrees of interaction with the public or with peers, such as receptionists in physician offices and hospitals. Individuals with low needs for affiliation who are not in managerial roles will be more comfortable in more isolated positions, such as research laboratories.

One more challenging aspect of the need for affiliation results from two conflicting forces. On the one hand, a healthcare professional may develop and enjoy strong personal connections with his or her patients. On the other hand, too much emotional involvement can be draining, eventu - ally resulting in burnout, especially for healthcare professionals who deal with patients who do not recover or die.

Motivational needs theory is not truly a theory, as no statements of cause and effect are present. The approach has been most use - ful in helping predict the types of jobs best suited to various individual personalities, as well as a person’s chances for success in managerial positions.

Herzberg’s Two-Factor Theory Two-factor theory has also been described as motivation- hygiene theory . Frederick Herzberg based the theory on results from interviews of more than 200 accountants and engineers (Herzberg, Mausner, & Snyderman, 1959). An analysis of the answers identified two issues that play an important role in the workplace experience: hygiene factors and motivational factors.

Table 12.4 defines these factors.

Table 12.4 Hygiene and motivational factors Hygiene factors Motivators Wages Hours Working conditions Relationships with supervisors Relationships with peers Achievements Recognition Actual work or job Responsibility Chance for advancement or growth Dissatisfaction N o satisfaction Note: Factors range on a dissatisfaction–no satisfaction continuum. No satisfaction D issatisfaction Note: Factors range on a no satisfaction–satisfaction continuum. Source: Adapted from Whitsett & Winslow, 1967, and Ivancevich, et al., 1997.

Herzberg’s interviews revealed that hygiene factors, which are associated with the work context, were related to job dissatisfaction. In essence, the most that managers can achieve with hygiene factors is to keep those factors neutral, as they are not related to motivation. In this approach, the © Ryan McVay/Photodisc/Thinkstock ▲ ▲ Hygiene factors explain employee dissatisfaction. Content Theories of Motivation Chapter 12 term hygiene is similar to conditions in a hospital. A dirty hospital will make you sick (dissatisfac - tion), whereas a sparkling clean hospital will not make you well (no new satisfaction).

Motivators are derived from personal effort and performance. Achievements, recognition, increased responsibility, the opportunity for personal growth, and promotion to a higher rank all provide incentives to try harder. Perhaps most germane to healthcare, the actual job or work performed may incite the highest levels of effort. For example, an employee who enjoys working directly with patients likely feels personal satisfaction from such work. When patient interaction factors are present or are added to this person’s job, motivation increases. If the factors are miss - ing, no motivation occurs.

A series of challenges have been raised with regard to the two-factor theory. First, Herzberg chose to use the terms motivation and satisfaction interchangeably; however, the two represent differ - ent concepts. A person might say he is satisfied because “I don’t have to do anything—I just col - lect a check.” In other words, “I’m satisfied because I don’t have to be motivated.” A nurse might report both dissatisfaction and motivation at the same time when she says, “I hate working third shift (working conditions), so I’m going to try extra hard to get a promotion so I can work days.” The bottom line is that the theory only accounts for circumstances in which individuals are satis- fied and motivated or dissatisfied and unmotivated as a consequence.

Second, many note that accountants and engineers, whose interviews formed the basis of the study, are not necessarily representative of every type of occupation. These individuals tend to earn higher incomes and perform jobs that are more interesting than those available in different sectors and at different levels. Interviews of janitorial workers in a healthcare organization, for example, might yield different answers regarding workplace satisfaction and motivation.

Despite these criticisms, the theory helps explain workplace dissatisfaction in many healthcare settings. One strength of the two-factor theory, when compared with other need-based theories, is that the research was conducted in a work environment and was directed toward employment- related, rather than more general, motives. Furthermore, the concept of making jobs more inter - esting and more challenging resonates with managers, employees, and the academic community.

As a result, the two-factor theory continues to be a popular method for examining the workplace environment.

The next section discusses the differences between need-based theories and operant models of learning and motivation. It also examines how operant models of learning and motivation apply to healthcare settings. WEB FIELD TRIP How are your motivation skills? Imagine you are the home care director of a local hospice organiza- tion. You are responsible for establishing, implementing, and evaluating the goals of the program.

One of your primary areas of focus is to ensure that your staff of home care clinicians remains moti- vated in achieving these goals. Take a quiz to find out how you might perform in this role.

Visit ht tp: // w w w.mindtools.com . In the Search field, type “Motivation.” On the results page, select “How Good Are Your Management Skills—Team Management From MindTools.com” to access the quiz.

• What did the quiz identify as your motivational strengths?

• In what areas could you use improvement? Operant Models of Learning and Motivation Chapter 12 12 . 3 Operant Models of Learning and Motivation Among the key differences between the need-based theories and operant models is whether observable or unobservable processes are being examined. In the case of need-based theories, learning and motivation are processes that cannot be observed; operant models, however, exam- ine behaviors, which can be observed. Rather than learning something or being motivated, these approaches note acquired behaviors and changes in behaviors (Sk i n ner, 19 7 7).

Operant Conditioning B. F. Skinner (1953) developed the operant conditioning model based on previous research and theory building that examined external forces that shape behaviors. The term operant expresses the observation that individuals operate (that is, act on or act in) within the environment. People may at times respond to stimuli or even to reinforcers in a knee-jerk fashion. They will also, how - ever, change behaviors over time based on the consequences they encounter. Figure 12.2 presents a simplified version of the operant conditioning process.

According to operant conditioning, two consequences strengthen behaviors or increase the likelihood that a behavior will be repeated. Two additional consequences weaken behaviors or decrease the likelihood that those behaviors will reappear.

Consequences That Increase Behaviors The first consequence that increases or strengthens behaviors, positive reinforcement, occurs when a pleasant or pleasing consequence becomes associated with a specific behavior. For exam - ple, eating at a specific restaurant (behavior) equals enjoying great-tasting food (pleasant conse - quence), and working hard equals praise from the boss. Positive reinforcement can be observed when a consequence results in an increase in the behavior. Eating great-tasting food results in a return to the restaurant, and praise from the boss results in employees working harder. In a healthcare setting, seeing a patient recover after administering a medicine or providing some form of treatment that achieves the desired result has positive reinforcement properties. Being praised for making a good “save” by spotting a patient’s symptom that leads to a correct diagnosis is another example of positive reinforcement. In both of these examples, the employees involved are likely to try to replicate or repeat behaviors that led to the desirable outcomes.

The second consequence that increases or strengthens behaviors is negative reinforcement, one of the most misunderstood concepts in organizational behavior. To clarify, this concept involves the reinforcement or replication of a behavior following exposure to a negative stimulus that will only go away when the behavior is produced. The more the behavior is produced, the less expo - sure there is to the negative stimulus. To demonstrate this reinforcer, consider a lab rat that has Figure 12.2 A simplified operant conditioning model f12.02_HCA340.ai Behavior Consequence Operant Models of Learning and Motivation Chapter 12 been wired so that it can be continuously shocked. The only way to stop the shock is for the rat to touch a small metal bar in one corner of the cage. Doing so breaks the circuit and stops the pain. After a few episodes, the paranoid rat will stand beside the bar, waiting for the next shock to begin so that he can immediately put a stop to it. The behavior (bar hitting) has been strength- ened and increased. In the healthcare industry, negative reinforcement occurs when someone takes medicine to reduce ongoing discomfort, such as an antacid for a stomachache or an aspirin for a headache. On the job, joking to break up the tension of an overly serious meeting, if it works, may become a more regular behavior.

Consequences That Decrease Behaviors Punishment is an unpleasant consequence linked to a behavior, often resulting in the disap - pearance of the behavior. If a different rat in the same cage touches an electrified metal bar and receives a shock, the rat will soon cut a wide path away from the bar. The behavior (bar hitting) has decreased. A healthcare employee who puts a patient in danger will likely be disciplined by being suspended or put on probation, with the expectation that the employee will not repeat the behavior.

Punishment is often confused with negative reinforcement, but two key differences exist. First, punishment is an unpleasant consequence that follows the performance of a behavior, whereas negative reinforcement is an unpleasant event that precedes the performance of a behavior.

A manager who yells at employees for loitering around the water cooler to get back to work, punishes the behavior of goofing around. If the same manager instead says, “No one gets to go home until this project is finished,” the manager has established negative reinforcement. The behavior of working and finishing the job is the best way for the employees to get out of the situation.

Extinction takes place in two ways. The first occurs when a behavior meets with no conse - quence—neither positive nor negative. Over time, such a behavior tends to disappear. Someone who uses a word or makes a gesture that others do not understand and receives no reaction as a consequence will eventually abandon the word or gesture. The second form of extinction involves removing consequences that appeared previously, by stopping the use of either positive reinforce - ment or punishment. For example, consider an employee who has consistently been praised for being friendly and helpful with patients but then stops receiving that positive attention. Unless the employee enjoys the inherent rewards of being friendly and helpful, he may become more complacent over time. A second employee is punished for not washing her hands by being sent home early, losing most of a night’s pay. At first, she likely will start to wash her hands as required.

If the employee forgets and does not clean up but is not punished, she may, over time, return to skipping this important step (Skinner, 1974b).

Table 12.5 provides examples of operant consequences in the workplace. These consequences can be delivered in a variety of ways to shape employee behaviors. In essence, they can help guide or teach the employee to achieve at higher levels (Skinner, 1978).

Schedules of Reinforcement The various forms of reinforcement can be delivered in several ways. Shaping programs seek to increase certain target behaviors, either on the job or elsewhere. To achieve these goals, rein - forcements are delivered using various schedules. Continuous reinforcement means the reinforcer will be delivered every time a behavior occurs. Administering this approach may be difficult because it requires constant monitoring and watching for the desired or target behavior, which may be expensive. Operant Models of Learning and Motivation Chapter 12 Table 12.5 Operant consequences at work Consequences that decrease behaviors Examples Positive reinforcementPay Praise Promotion Benefits Inclusion in high-status groups or teams Seeing a patient heal or recover Negative reinforcement Meeting deadlines (patient billing notices) Punishment Discipline Being chewed out Termination Unwanted transfer Unpleasant task assignment Demotion Extinction Ignoring an unwanted behavior Removing a previously granted reward, such as praise or bonuses Ceasing punishment for behaviors, such as punishing someone for not using proper safety measures Intermittent reinforcement involves delivering reinforcements for some, but not every, instance of a desired or target behavior being exhibited. Intermittent reinforcement programs routinely take place in work sites such as those displayed in Table 12.6.

Table 12.6 Reinforcement schedules Schedule type Examples Behavior maintenance Fixed interval Weekly, monthly paycheck Variable interval Promotion for continuous high performance Pay raises for high performance granted on random timetables Behavior occurrence Fixed ratio Pay per medical service delivered Variable ratio Randomly delivered praise and compliments for quality Based on Skinner.

The first two programs involve maintaining a behavior over time. Fixed-interval reinforcements are delivered at uniform time periods for as long as the behavior continues. Variable-interval rein - forcements are distributed over random time periods, again for as long as the behavior continues.

The second two programs grant reinforcements based on behavioral occurrences. Fixed-ratio reinforcement will be granted on a fixed number of behaviors, such as every third instance or every fifth occurrence. Variable-ratio reinforcement varies the number of behavioral occurrences. Operant Models of Learning and Motivation Chapter 12 Other Elements of Learning and Motivation Skinner noted two additional elements pertaining to the connections between reinforcement and the acquisition of behaviors. The principle of immediate reinforcement suggests that the closer in time a reinforcer appears following a behavior, the more powerful the reinforcer becomes. Thus, immediately delivered rewards and punishments are more powerful than those delivered follow - ing a delay.

Response discrimination means that a behavior must be shaped to a specific form in order to gain a reinforcer. When teaching a person how to perform a medical procedure, the first attempts may not be precise. Positive reinforcement should not be delivered until the procedure has been accurately and successfully completed.

Overuse of Punishment Skinner believed that punishment creates a trap for parents, teachers, managers, and government officials that over-rely on it. Punishment has several disadvantages. For one, it focuses attention on unwanted behaviors rather than on desired behaviors. In practically any situation, it makes sense to point out the behaviors a manager hopes to encourage (trying hard, staying on task) rather than the ones the manager wants to discourage (goofing around, wandering away).

At work, managers tend to punish for three reasons: it is a display of personal power; it was what they observed while training to become managers; and it is quick and easy. Most modern management experts recommend saving punishment for extreme circumstances, such as safety rules violations and clearly inappropriate behaviors. The rest of the time, positive reinforcement offers the better alternative. To paraphrase the popular 1980s book The One-Minute Manager, “Help people reach their potential: Catch someone doing something right” rather than looking for someone doing something wrong to punish (Blanchard & Johnson, 1981).

Organizational Behavior Modification Many managers prefer programs with easy-to-follow steps that enhance performance in some way. Organizational behavior modification (OB Mod) meets these requirements (Luthans & Kreitner, 1975). The system, which has been successfully applied in several business organiza - tions, follows these steps:

1. Identif y critical, performance-related behaviors. 2. Find ways to observe and count the behaviors. 3. Conduct a functional analysis associated with the behaviors. 4. Design a program to change or modify the behaviors. 5. Run the program. 6. Follow up.

Critical Behaviors Perhaps the most important step in the plan is the first one. If unimportant behaviors are identi - fied, then every step that follows will be geared toward the wrong activities. Also, it is important to distinguish between behaviors and attitudes. From a behaviorist perspective, when attitudes rather than behaviors become the starting point, there is no effective way to make the system work, because attitudes cannot be observed. Only actual behaviors can be observed and then influenced or changed. In healthcare, examples of critical behaviors include the following: Operant Models of Learning and Motivation Chapter 12 • Collecting accurate patient information on a timely basis • Reporting changes in patient status to the appropriate person • Updating medical records when required • Following sterilization protocols • Observing safety rules • Protecting patient privacy • Being professional when dealing with family members and visitors Observe and Count Behaviors Numerous methods may be used to monitor behaviors. Managers and physicians can directly view employees on the job, video surveillance may be used, or activities may be observed through devices such as a see-through mirror. Records can be examined to ensure they have been cor - rectly filled out and updated.

Functional Analysis A functional analysis involves determining which stimuli lead to desired behaviors and which lead to undesired behaviors. Stimuli related to desired behaviors include the presence of a super - visor, reminders through signs posted in the workplace, and even the company of a well-respected colleague or peer. Stimuli that precede undesired behavior can take a variety of forms. A clock in plain view can cause employees to anticipate breaks, lunchtime, and the end of the day rather than the work at hand. A visible water cooler with a nonchalant employee lingering beside it invites others to come and visit rather than staying on task. Even an attractive coworker may distract a worker from a job assignment.

In one situation, Luthans observed that the water cooler enticed workers to wander off station, thereby not tending to unfinished work. In addition, social clusters tended to form in areas that were not observable from management offices. The presence of a supervisor led to more attentive work behaviors.

Design a Program In keeping with the spirit of Skinner’s work, the OB Mod program tends to avoid an emphasis on punishment, although it can be incorporated into the program. Luthans recommended changing behaviors through means other than punishment, such as: 1. Positive reinforcement only, in which desired behaviors are identified and rewarded 2. Positive reinforcement and punishment, where desired behaviors receive rewards and unde - sired behaviors are punished 3. Positive reinforcement and extinction, in which desired behaviors are rewarded and either the stimuli that lead to pleasant consequences associated with undesired behaviors are removed (e.g., take out the water cooler) or the consequences themselves are somehow diminished Medical managers in a variety of organizations are able to provide many forms of positive rein - forcement, starting with praise and including items such as “employee of the week” recogni - tion, small prizes for specific activities, higher performance appraisal ratings, and so forth. In healthcare settings, punishment applies to behaviors that injure patients or expose employees to disease, or those that create other dangers. Violations of privacy may be punished as well, as Operant Models of Learning and Motivation Chapter 12 would other forms of unprofessional behavior that could lead to consequences for the organiza- tion. Some creative healthcare managers may be able to identify ways to include extinction into a program.

Conduct the Program When conducting the program, adequate instruction should be given to all parties involved.

Supervisors need to know what to observe and how to respond (reward, punish, extinction).

Employees should be notified that key behaviors will be recognized and will result in the stated outcomes.

Follow Up The follow-up step ensures that the desired behaviors were identified, that functional analysis correctly identified pathways to desired and undesired behaviors, and that the program achieved the intended results. Programs that succeed may be institutionalized or refined for future use.

Programs that do not lead to positive results are evaluated, beginning with the first step. Were the correct behaviors identified? If so, then other elements of the program deserve attention. It may have been, for example, that employees did not truly desire the rewards that were offered.

The next section analyzes approaches that deal with more mental aspects of motivation. It also explains how managers can use ideas from cognitive models of motivation in the healthcare environment. CASE The Negotiation Margaret Contras served as the chief negotiator for the nurses’ union at Memorial General Hospital.

Every two years, the union would bargain for wages, hours, and conditions of employment with the hospital’s negotiating team. The upcoming session promised to present additional challenges to both sides of the table.

Memorial General faced difficult financial circumstances. A new medical facility that had opened in the city during the past year was taking away significant numbers of patients, some of which involved the more lucrative elective surgeries (e.g., facelifts, cosmetic procedures), as well as more expensive medical treatments that generated revenues for the hospital, including cardiac rehabilita - tion and others. As a result, the hospital’s annual revenues had declined by nearly 5% in the past year, while its expenses (including payroll) stayed constant. The management team had been able to make up the difference by cutting some marginal costs, including closing parts of the facility at night, reducing payroll by not replacing some individuals who had left the organization, and more careful scrutinizing of medical, janitorial, and office supplies. However, the managers knew that these efforts would provide only a temporary patch for the situation.

Margaret was to voice complaints in two primary areas. First, several nurses reported that they were being asked to cover larger numbers of patients and medical activities during each shift, as some of the staff who had not been replaced were fellow nurses. The added workload created higher levels of stress for those nurses. Second, the pay scale at Memorial had flattened over the past two years.

Many nurses had not received any raises during that time, while the cost of living in the area had risen by nearly 4%. The nurses noted that their peers in other medical situations, such as doctor’s offices, medical group practices, and other nursing facilities, had received increases in wages that (continued) Cognitive Process Motivation Models Chapter 12 12 . 4 Cognitive Process Motivation Models One of the primary criticisms of the reinforcement-based approaches to motivation and learn- ing has been that the theories do not explain complex reasoning processes. Such thought pro - cesses deserve attention, especially in complex environments such as healthcare organizations.

In essence, employees are likely to consider their circumstances and then respond in some way.

Two cognitive process models of motivation include Adams’s equity theory and Vroom’s expec - t a nc y t he or y.

Adams’s Equity Theory and Organizational Justice Among the more common factors that might influence a per - son’s behavior on the job is the perception that a given process is fair. Equity theory, as developed by J. Stacy Adams (1963, 1965), explains how employees might react to perceptions of both fairness and inequity. The theory explains various responses in healthcare organizations as well as other settings.

Inputs and Outcomes At work, people exchange inputs for outcomes. Inputs include everything an employee trades to an organization, expect - ing something in return. Examples of inputs include educa - tion, experience, special skills, levels of effort and productivity, helpfulness to others, creativity or suggestions, grooming and totaled as much as 10% in the same time period. Margaret was concerned that this trend would create additional turnover, leading to hires of new, inexperienced employees trying to handle the duties of longer-term, veteran nurses.

The local college also played a role. Due to state funding cuts, the administration was forced to reduce the number of nursing students it could teach by nearly 50%. The next graduating class would be the first to exhibit the results of the decision. New graduates dropped from 52 the previ - ous year to 23 for the current year. Several health organizations in the area offered signing bonuses in order to attract these graduates. Margaret became highly concerned that these individuals would actually earn as much as, or more than, nurses at Memorial General who have far greater experience.

The only positive element of current negotiations that Margaret could see was that Memorial General’s administration had always taken a cooperative, rather than adversarial, approach to bar - gaining. She and her fellow nurses perceived that they were being treated with respect and in a professional manner.

In answering the following questions, it may be helpful to review Sections 12.2, 12.3, and 12.4.

1. Using Herzberg’s two-factor theory as a guide, explain the issues in this situation. 2. Using Adams’s equity theory as a guide (see Section 12.4), explain the issues in this situation. 3. Using Vroom’s expectancy theory as a guide (see Section 12.4), explain the issues in this situation. 4. How should the two sides in this circumstance achieve a contract that would address the prob - lems present in this case? © Stockbyte/Thinkstock ▲ ▲ Adams’s equity theory has its basis in organizational justice concepts. Cognitive Process Motivation Models Chapter 12 cleanliness, attention to patient needs, maintaining confidentiality, and other duties. Outcomes are the items the organization exchanges for inputs. Outcomes include pay, praise, chances to be promoted, status symbols (corner office; reserved parking space), company benefits, job assign- ments, recognition, job security, and being included in organization plans and decisions.

Presence of a Referent Other A referent other is a person (or possibly a group) chosen by an employee for purposes of making social comparisons. In other words, most employees tend to single out someone at work or in some other organization for the purpose of examining relative levels of inputs and outcomes.

Most of the time, a referent other will be someone who was hired at about the same time and performs the same or a comparable job. In other circumstances, different forms of referents are selected, as displayed in Table 12.7.

Table 12.7 Potential referent other comparisons Comparison type Description Self inside the organization The employee compares a new position or job to a previous position or job in the same organization.

Self outside the organization The employee compares a current position or job to a previous position in a different organization.

Other inside the organization The employee compares a current job or position with another person or group within the same organization.

Other outside the organization The employee compares a current job or position with another person or group in a different organization.

The Comparison No matter which type of referent other emerges, the employee compares input–outcome ratios— that is, give–get relationships, or “what I give and get versus what my referent other gives and gets.” Personal outcomes versus Refer ent other outcomes Personal inputs Refer ent other inputs Equity Perceptions Equity occurs when the ratio comparison is perceived as being equitable, in balance, or fair. For instance, Joe serves as a nurse in a mental health facility. His inputs include distributing medi - cines on a nightly basis, assisting a patient during exams under the supervision of a physician, tending to a patient’s needs when an individual is moved to the infirmary, and providing help in emergency situations. Joe’s outcomes include pay of $22 per hour and flexible scheduling in which he can switch shifts with other employees if he desires a particular night free.

Susan is the nursing supervisor. Her inputs include hiring, training, and firing employees; com - pleting daily report sheets; working on a fixed schedule with no shift switching; and assisting with nursing duties when required. Her outcomes include pay of $27 per hour and an extra week of paid vacation (four instead of the three that all other nurses get) each year.

Even though Susan earns $5 per hour more and has more vacation time, Joe believes the differen - tial is equitable. Susan gives more to get more; Joe gives less and receives less. When such a sense Cognitive Process Motivation Models Chapter 12 of equity or equilibrium exists, behavior is maintained. The definition of motivation as noted at the start of this chapter includes “what maintains behavior.” In this instance, a sense that things are equitable or fair means Joe will keep working at the same pace and with the same level of intensity.

Perceptions of Inequity Many times, a review of personal and referent other inputs and outcomes leads to the perception that the formula is not in balance. This circumstance—inequity or disequilibrium—results in a strong motivational force (a cognitive process) to restore equilibrium. In other words, the indi - vidual feels compelled to somehow adjust the components in the input–outcome ratio. Table 12.8 represents the types of reactions that are possible.

Table 12.8 Reactions to perceptions of inequity Activity Example Change personal outcomes Ask for a pay raise Change personal inputs Try harder or reduce effort Influence referent other outcome Encourage referent other to ask for a raise Influence referent other inputs Encourage referent other to try harder or reduce effort Change referent other Look at outcomes and inputs of someone different Rationalize Add elements to the formula, such as a time horizon Leave the field Quit the job One set of reactions to inequity involves a perception described as positive inequity, as reflected in this formula:

Personal outcomes > Refer ent other outcomes Personal inputs Refer ent other inputs This formula suggests that the person involved has determined that he or she is overpaid, because the person’s outcome–input ratio is more generous or valuable than the ratio the referent other experiences. Using the potential responses noted in Table 12.8, a person who felt overpaid could try harder and produce more inputs to justify the difference, change comparisons to a referent other who earns more, or rationalize that the pay difference was based on seniority or some other factor not previously considered.

The other form of disequilibrium, sometimes called negative inequity, is shown as:

Personal outcomes < Refer ent other outcomes Personal inputs Refer ent other inputs This situation reflects feeling underpaid. A person who believes he or she is underpaid could ask for a pay raise; reduce outputs (don’t try as hard); conclude that although the employee currently experiences inequitable treatment, management will eventually make things right through a pro - motion or some other future adjustment to outcomes; or make plans to leave and quit. Cognitive Process Motivation Models Chapter 12 Support for Equity Theory and Organizational Justice There is significant theoretical support to validate equity theory. The idea that people exchange inputs for outcomes in all types of social interactions with others has its basis in psychological contracts (Schein, 1982). The idea that people compare themselves to one another is based on social comparison theory (Festinger, 1954, 1957).

Furthermore, the premise that inequity exists when input–outcome ratios differ is founded in the principles established by the theory of distributive justice—people should receive in propor - tion to what they give in society, which also applies to the allocation and amount of outcomes.

Awareness of equity and inequity are influenced by perceptions of procedural justice, or evalua- tions of the fairness of a process, such as a performance appraisal or pay raise system. Distributive justice and procedural justice combine to create perceptions of overall organizational justice (Dailey & Kirk, 1992).

Finally, the tendency to act on disequilibrium derives from conceptualizations of cognitive dis - sonance (Festinger, 1957). Cognitive dissonance, or mental disharmony, creates a mental force seeking to resolve the discord or dissonance.

Complications Although organizational research supports the predictions of reactions by individuals to per - ceptions of inequity (Scheer, Kumar, & Steenkamp, 2003), a series of complications have been associated with the work. One of those complications involves equity sensitivity, or the range of reactions to perceptions of inequity. Equity “sensitives” believe firmly in reciprocity and become quickly motivated to resolve feelings of being over- or underpaid. Equity “benevolents” are more altruistic and less bothered by underpaid or negative equity relationships. Equity “entitleds” respond most vigorously to negative equity or underpaid circumstances and may remain frus - trated until positive equity or an overpaid comparison appears (Sauley & Bedeian, 2000).

In addition, feeling overpaid does not seem to change a person’s behaviors at work, possibly because the individual quickly rationalizes differences in outcomes (Steers, 1996). The theory does not account for the power of the rationalization process in overpaid, as opposed to under - paid, situations.

On a more practical level, the social comparisons that could be made within an organization are both countless and unpredictable. Managers do not choose who someone singles out for a social comparison, and the choice could be completely inappropriate. For instance, a new, fresh-out-of- dental-school hygienist who compares herself to someone with eight years of experience might result in inaccurate perceptions of deserved outputs and inputs.

Finally, equity theory may not represent thought processes in other cultures. Many national cul - tures do not contain strong feelings regarding distributive justice. Also, in former communist countries, feelings of entitlement can supersede perceptions of equity and distributive justice.

Thus, many organizational behavior experts view the theory as culture bound (Giacobbe-Miller, Miller, & Victorov, 1998). Given the number of foreign-born physicians and medical profession- als working in the United States today, healthcare managers should consider this issue in imple - menting the basic concepts.

Managerial Implications Despite the concerns with equity theory, however, many healthcare managers may find that its principles offer value. To begin, a supervisor can make certain that the equity comparisons made Cognitive Process Motivation Models Chapter 12 by top performers receive the most attention. Doing so can go beyond pay and benefits. For example, top performers may receive preferential treatment in terms of scheduling breaks dur- ing the work day, vacations, and other nonfinancial signals related to their worth. At the same time, each employee should believe that the reward system is fair and is not simply based on the manager’s personal preferences.

Managers can also employ equity theory to understand why workers become dissatisfied and seek to leave a company. In essence, it provides a framework for understanding how employees react to how they are treated by the organization and specific managers.

Vroom’s Expectancy Theory Vroom (1964) provided a second cognitive process theory to explain the relationships between organizational circumstances and employee motivation. Several variations of the theory’s con - cepts may be found in the literature. Each version contains three primary elements: expectancy, instrumentality, and valence.

Expectancy summarizes an individual’s belief that a given level of effort will result in success - ful performance of a task. A medical student who expresses complete confidence that she will pass her licensure exams expresses a high expectancy. Another student who believes passing the exam on the first try will not be possible has an extremely low expectancy value. Any provider who does not believe he can cure a patient experiences a lower level of expectancy; when the same provider has great confidence the patient can be cured, expectancy takes on a high value.

Expectancy can be depicted as follows: Effort → Performance Instrumentality reflects an individual’s belief that successful performance of a task will result in a specific outcome or reward. A physical therapist who believes he can treat an injury and will be fully financially compensated by the patient and his insurance company expresses a high instrumentality score. An intern who believes her supervising physician holds a grudge and will not write a positive endorsement of her work, no matter the quality of that work, has an instru - mentality score that is low or even zero. Instrumentality may be expressed as this linkage: Performance → Reward Va l e nc e consists of two components. The value of the reward to the person constitutes the first.

If a pharmaceutical company holds a sales contest in which the reward for winning is an all- expenses-paid vacation to Hawaii, the majority of salespeople will highly value the prize. Thus, the valence of the outcome will be high. If the same contest yields a prize of a free dinner at a local restaurant, and most of the salespeople dine out all the time as part of their travels (which means they are not excited at all about the reward), then the valence of the outcome will be low or zero.

The second component of valence is the value associated with achieving a goal or successfully completing a task. Winning the contest provides a valence associated with doing the best job dur - ing a specific time period on a given task.

Calculating a Motivational Force Individual authors have presented several versions of the combinations of these variables. A com - mon method uses a multiplicative model, as follows: Motivational force (effort) = Expectancy × Instrumentality × Valence Cognitive Process Motivation Models Chapter 12 Values can then be assigned to each vari- able. Expectancy may be rated from 0 to 1 or 0 to 100%. A score of 0 means the indi - vidual believes no linkage between effort and performance exists, or “No matter how hard I try, I can’t do it.” A score of 0.5 or 50% indicates the person believes he or she has a 50–50 chance of success, given a specific level of effort. A rating of 1 or 100% indi - cates the person has complete confidence that given a certain level of personal effort, the individual can complete the task or achieve the goal.

The same formulation applies to instru - mentality. A score of 0 means the person does not believe a reward will be delivered for successful performance. A score of 50% suggests the individual is uncertain about whether the reward would be delivered. A value of 100% means the person expresses complete confidence that achieving a goal or successful per - formance will be rewarded.

Assigning values to valence is more problematic. Scales can be used to indicate the value of a reward from 1 (no value) to 7 (great value), or sets can be used to indicate low, medium, and high degrees of valence. The concept behind these ranges is to note that some valences are more powerful than others.

Using this approach makes it possible to see differences in the degree of motivational force and to make predictions about the level of effort that will be given (see Table 12.9). Table 12.9 Degrees of motivational force Motivational Force = Expectancy× Instrumentality× Valence High = High× High× High Moderate = High or Moderate× Moderate× High Low = Low or Moderate× Low or Moderate× Low or Moderate The highest level of effort would be expected when the individual believes he or she can suc - cessfully complete a task (high expectancy), that successful completion of the task will result in a reward (high instrumentality), and that the reward itself has value (high valence). Under any other circumstance, the degree of motivation diminishes. Notice also that if a score of 0 is assigned to any of the three variables, the resulting level of motivation will also be 0.

Advantages of Expectancy Theory Expectancy theory has been a well-respected approach to understanding motivation in the work - place for several decades and for several reasons. First, the theory concentrates on workplace motivation rather than motives in other circumstances. It applies to specific employment activi - ties, goals, and rewards. © Pixland/Thinkstock ▲ ▲ Motivation only occurs when valences, expectancies, and instrumentalities all reach high levels. Cognitive Process Motivation Models Chapter 12 Second, using the formulation shown in the previous section, expectancy theory explains not only circumstances in which employees will be motivated but also situations in which they will not be motivated. An organization that has not given pay raises or any other incentives for per- formance over the past three years should not be surprised by the levels of effort exhibited by its employees. When a linkage between effort and performance cannot be identified, motivational levels decline. Furthermore, managers who fail to recognize the things that employees value may offer rewards with little or no meaning to those employees.

Third, the theory incorporates both intrinsic and extrinsic motives. An intrinsic valence is the reward a person experiences after achieving a goal, such as a feeling of pride, accomplishment, or self-efficacy. Intrinsic valences accompany the extrinsic valences, or the strength of the rewards given by others (Porter & Lawler, 1968). In medical circumstances, helping others, relieving suf - fering, healing patients, and providing quality care to patients and their loved ones all constitute a powerful set of intrinsic motives for many healthcare employees in a variety of jobs. Managers should never underestimate the importance of these intrinsic valences.

Fourth, there is consistent research to support expectancy theory (Donovan, 2001; van Eerde & Thierry, 1996). Many managers believe that the theory offers down-to-earth, concrete methods for seeking to improve employee effort and levels of motivation. In essence, applying expectancy theory involves three things: working to make sure employees can complete assigned tasks, link - ing performance to the reward system, and making sure employees are rewarded with the things they value.

Does Money Motivate Healthcare Workers?

One continuing debate in organizational behavior focuses on the role of money as a motive.

In some of the theories presented in this chapter, pay only manages to dissatisfy employees. In others, money includes the concept of valence, or something that holds value and thus serves to motivate individuals.

Money in healthcare holds an even more unique role. People working in the industry clearly do so to support themselves and their families. And yet much of their work concentrates on the help - ing aspects of serving patients. Employees balance considerations, such as the desire for a quality standard of living, with other factors.

Recently, many private practice physicians have encountered circumstances in which some patients have made fewer trips to the doctor’s office, and others have decided to forgo more expensive (and lucrative to physicians) elective procedures. The result has been an increase in doctors filing for bankruptcy (Kavilanz, 2013) and, as a result, some regions are losing access to certain forms of healthcare. In several instances, the physicians had not lost any major medi - cal malpractice lawsuits and were considered to be highly respected doctors. Instead, economic downturns had shaped patient decisions regarding healthcare. In addition, declining insurance reimbursements, changing regulations, the rising costs of malpractice insurance, drug costs, and other business necessities were deemed as culprits.

In the coming years, the role of money as a motivator for individuals in the healthcare system will continue to receive scrutiny. Doctors, nurses, and others employed in the system battle expensive training programs, long hours on the job, work-related stress, and other factors, all while seeking to serve others. Those involved in managing the system will need to discover ways to make sure the industry attracts and retains quality employees. The role money plays in that system remains to be seen. Cognitive Process Motivation Models Chapter 12 CASE Debbie’s Dilemma Debbie Vestica decided to look for a new job on a day that should have been filled with joy.

She had just completed a master’s degree in nursing and had been given a substantial increase in pay, along with new benefits. Other factors, however, greatly diminished the reward she had just received.

Debbie began working as a nurse in a local pediatric physician’s medical group. Three doctors and three nurses made up the medical staff. Two of the nurses completed training at the licensed practi- cal nurse (LPN) level, while Debbie held the rank of registered nurse (RN). Due to this difference in educational attainment, Debbie was expected to supervise the other two nurses. The problem she faced was that the two nurses often treated her more as a peer, or even as a subordinate, rather than as a supervisor.

To complicate matters, the two LPNs had been on staff for four and five years, respectively, while Debbie had only been employed by the organization for two years. Still, when hired, she was told to assume a supervisory role. At first, Debbie chose not to confront the two more experienced nurses, hoping that over time she would be able to manage them more effectively by not trying to use forceful or directive tactics.

One year later, Debbie discovered that although her pay was slightly above average for RNs in the area, her pay differential with the LPNs was only $3 per hour. She earned $30 per hour ($60,000 per year), whereas the LPNs earned $27 per hour ($54,000 per year). Their pay ranked them above nearly all LPNs in the state. Given the additional duties she was expected to complete, Debbie found the pay differential to be unsatisfactory.

After two years on the job, Debbie began a master’s program designed to achieve the designation of clinical nurse specialist with an emphasis in children’s health. She devoted considerable time and money to obtaining the degree, although the physician’s group did contribute 50% of her tuition and book costs.

On graduation day, Debbie met with the three physicians. They all generously praised her efforts and promised her a new status level that included having her own office in the complex. They also granted her a raise of $7 per hour, raising her annual salary to $74,000, in return for additional duties and responsibilities.

The turning point occurred when Debbie overheard the two LPNs talking in the office break room.

Upon finding out about Debbie’s new pay raise and status, the LPNs confronted the three physi - cians, demanding an additional increase in pay as well. Sensing a major confrontation, the physi - cians had decided to raise the pay of the two by $5 per hour, to $32 per hour or $64,000 per year.

That amount was higher than what Debbie had earned as an RN and as an RN attending graduate school. Believing that she would never receive the proper pay differential that she deserved in this practice, Debbie decided it was time to seek employment elsewhere.

1. Use Herzberg’s two-factor theory to explain Debbie’s level of motivation. 2. Use Adams’s equity theory to explain Debbie’s decision to look for work elsewhere. 3. Use Vroom’s expectancy theory to explain this situation. 4. If you were advising the three physicians in the organization, what would you tell them they should have done when confronted by the two LPNs? Defend your advice. Key Terms Chapter 12 Chapter Summary Motivation is what starts, maintains, and stops behaviors on the job. Content theories of moti- vation examine factors within individuals—notably, needs—that lead to behaviors. Historically, content theories described the essence, or content, of motives, which take the forms of unsatis - fied or unfulfilled needs. Operant process theories of motivation explore external factors that increase and decrease behaviors using Skinner’s behaviorism principles. Cognitive process theo - ries of motivation examine the thought processes or mental reasoning processes that lead to behaviors.

Content theories include two satisfaction–progression models: Maslow’s hierarchy of needs and Alderfer’s existence, relatedness, and growth (ERG) theory. McClelland’s needs theory identifies achievement, affiliation, and power as three key motives at work. Herzberg’s two-factor theory argues that hygiene factors dissatisfy employees and fail to motivate them; as a group, these fac - tors should be kept neutral. Motivation occurs when the satisfiers are present, which means that achievements, recognition, the chance for advancement or promotion, responsibility, and mean- ingful work should be built into the employment system.

Skinner’s operant conditioning model contains four elements: Positive and negative reinforce - ment increase behavioral responses, whereas punishment and extinction decrease behaviors.

Skinner argued that a focus on behaviors is the key to enhancing desired outcomes. Positive reinforcement may be delivered through fixed- and variable-interval and fixed- and variable-ratio schedules, which shape and refine desired behaviors. Due to its many limitations, punishment should be avoided except for extreme circumstances.

Luthans’s organizational behavior modification program (OB Mod) begins with identifying key performance-related behaviors. Managers then can find ways to measure and count those behav - iors. A functional analysis categorizes the stimuli, organism, behavior, and consequences related to desirable and undesirable behaviors. A program that uses the variable positive reinforcement, punishment, or extinction can then be designed.

Equity theory notes that employees exchange inputs for outcomes and that they have a natural tendency to make social comparisons, most notably with a referent other. The comparison exam - ines the ratio of a person’s inputs to outcomes in relation to the input–outcome ratio provided to the referent other. When the comparison results in a perception of equity, behavior is main - tained. When the comparison reveals inequity, a strong motivational force emerges as the person seeks to restore equilibrium by changing personal inputs or outcomes, by identifying a new refer - ent other, by rationalizing, or by seeking to leave the organization.

Expectancy theory consists of expectancies, instrumentalities, and valences. Expectancy repre- sents the degree to which an individual believes that a given level of effort will result in successful performance of a task. Instrumentality reflects an individual’s belief that successful performance of a task will result in a specific outcome or reward. Valences are the things that employees value.

The highest level of motivation occurs when the values of all three variables are high; motivation diminishes under any other circumstance.

Ke y Te r m s cognitive process theory of motivation that examines the thought processes or mental rea - soning processes that lead to behaviors Additional Resources Chapter 12 content theory study relating to the essence or content of motives, which take the form of unsatisfied or unfulfilled needs as the factors that motivate employees expectancy the degree to which an individual believes a given level of effort will result in suc - cessful performance of a task extinction no consequence occurs following a behavior, which decreases or weakens the behavior extrinsic valence the strength of the rewards given by others hygiene factor job-related factor that leads to dissatisfaction and the lack of motivation instrumentality the degree to which an individual believes successful performance of a task will result in a specific outcome or reward intrinsic valence the reward a person experiences after achieving a goal; examples include a feeling of pride, accomplishment, or self-efficacy motivation what starts, maintains, and stops behaviors motivator job-related factor that is derived from personal effort and performance need for achievement the degree to which an individual exhibits the drive to excel and gener - ate accomplishments need for affiliation the need for close interpersonal relationships need for power the drive to make others behave in ways they would not otherwise choose negative reinforcement in an aversive situation, a behavior is performed that stops the nega - tive event, which increases or strengthens the behavior operant process theory of motivation that explores external factors that increase and decrease behaviors using Skinner’s behaviorism principles organizational justice the combined perception of distributive and procedural justice positive reinforcement a pleasant or pleasing consequence that increases or strengthens behaviors punishment an unpleasant consequence linked to a behavior, which decreases or weakens the behavior valence the value associated with a given reward or outcome Additional Resources Accel: Team Building Training and Development h t t p : // w w w.accel-team.com Human Resources: HR Village h t t p : //www.hrvillage.com PI Worldwide: HR Solutions h t t p : //w w w.piworldwide.com Critical Thinking Chapter 12 Critical Thinking Review Questions 1. Define motivation . 2. Name and define the three categories of motivation theories explained in this chapter. 3. What five needs appear in Maslow’s hierarchy? 4. What concept does Alderfer’s ERG theory add to Maslow’s hierarchy? 5. What three needs from McClelland’s need theory apply to healthcare situations? 6. Name the satisfiers and dissatisfiers present in Herzberg’s two-factor theory. 7. What two consequences increase or strengthen behaviors in operant conditioning? 8. What two consequences decrease or weaken behaviors in operant conditioning? 9. Describe continuous and intermittent reinforcement. 10. Define fixed-ratio , variable-ratio , fixed-interval, and variable-interval reinforcement . 11. What are the steps of organizational behavior modification? 12. What is a referent other in equity theory? 13. Explain the concepts of inputs and outcomes in equity theory. 14 . Describe the natures of positive inequity and negative inequity. 15. Explain the terms expectancy, instrumentality, and valence. 16 . In expectancy theory, what situation would lead to the highest level of motivation? Analytical Exercises 1. Which category of motivation theory holds the greatest promise for explaining motivation in healthcare circumstances—content, operant process, or cognitive process? Defend your a n swer. 2. What types of behaviors related to motivation would be most significant in the following employment situations?

• Pharmaceutical salesperson • X-ray technician in charge of machine repair and maintenance • Emergency room nurse • Receptionist for an eye doctor (ophthalmologist) 3. Other than needs (in general) as motives, what common elements can be found in the four content theories of motivation? 4. How well do Herzberg’s lists of satisfiers/motivators and dissatisfiers/hygiene factors apply to the following situations?

• An ambulance driver working the 12:00 a.m. to 8:00 a.m. shift • A dishwasher in a hospital kitchen • A physician in a private practice • A medical equipment salesperson who travels four days per week making sales calls Critical Thinking Chapter 12 5. Provide examples of four consequences of behaviors (positive and negative reinforcement, punishment, and extinction) in the following circumstances:

• A nurse sterilizing (or failing to sterilize) a person’s arm prior to giving an injection • A medical transcriptionist completing all records before the end of the month • A janitorial staff cleaning an emergency room in between uses • A psychiatrist diagnosing (or failing to diagnose) an individual requiring suicide-watch care 6. Would Luthans’s OB Mod model be useful in the following situations? Defend your answer.

• Hospital cafeteria • Overnight nursing care • Diagnostic laboratory 7. How would Adams’s equity theory apply to the following situations?

• A female nurse passed over for a promotion in favor of a male nurse with less experience • A surgeon not chosen by the chief of staff to perform an operation, when that surgeon believes he or she is the most qualified • An insurance claims representative discovers his or her salary is higher than claims reps in four other insurance companies 8. Make an argument suggesting that expectancy theory holds an advantage over all other motivation theories. (Consider the theory’s advantage in explaining situations in which employees are and are not motivated.)