EMPLOYEE MOTIVATION RELATED TO LEADERSHIP STYLES IN AMBULATORY HEALTHCARE SETTINGS
K. Tyler Chrest
A dissertation submitted In partial fulfillment for the degree of Doctor of Healthcare Administration
Franklin University Columbus, Ohio December 8, 2020 The Dissertation Committee for K. Tyler Chrest certifies approval for the following dissertation:
Employee Motivation Related to Leadership Styles in Ambulatory Healthcare Settings
Qualitative Methodology
Committee:
Dr. George Velez, D.H.A., Committee Chair
Dr. David Meckstroth, D.H.A., Committee Member
Dr. Dail Fields, Ph.D., Committee Member
______Dr. George Velez, D.H.A., Committee Chair
______Dr. David Meckstroth, D.H.A., Committee Member
______Dr. Dail Fields, Ph.D., Committee Member
______Dr. Gail Frankle, D.H.A., Program Chair
______Dr. Wendell Seaborne, Ph.D., Dean, Doctoral Studies
______Date of Approval
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ACKNOWLEDGEMENTS
First, I would like to express my gratitude for my phenomenal Dissertation Committee.
Dr. George Velez, who served as my Committee Chair, was truly a guiding light during this research. His extensive field experience, and honest and straightforward approach to feedback resulted in the development of a great final product. I appreciated his sense of urgency, especially when I needed some guidance while writing in the evenings or weekends. My
Dissertation Committee members, Dr. David Meckstroth and Dr. Dail Fields, together continued to push me to think in different ways, and provided unique, insightful perspectives during the writing process. I appreciated the insight early on in the program from Dr. Leslie King, and the technical methodological guidance from Dr. Bora Pajo, especially when I was overthinking even the smallest things.
Second, I would like to thank a few professors and advisors from my Bachelor’s and
Master’s programs who motivated me to continue researching in healthcare, and energized me to develop an even deeper passion for healthcare leadership. Some of those individuals are: Dr.
Wayne Nelson, Dr. Mary Helen McSweeney-Feld, Dr. Patricia Alt, and Dr. Michael Porter. I truly would not have continued on to this level in my academic pursuits if it were not for the inspiration from all of these talented individuals along the way. I also cannot express enough gratitude toward Dr. James Nelson, for serving as a close Ph.D. mentor and sounding board during even the most challenging and overwhelming stages of this journey. Your intellect, wisdom, and dedication are a model to live by. Finally, I would like to express my appreciation to my family and friends for their unwavering support during this Dissertation journey. I am forever grateful not only for your support, but also for your understanding of the time sacrifices that are necessary to complete a research work of this nature.
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ABSTRACT
EMPLOYEE MOTIVATION RELATED TO LEADERSHIP STYLES IN AMBULATORY HEALTHCARE SETTINGS
by K. Tyler Chrest
The healthcare industry is continuously faced with increasingly difficult challenges. This is especially true in rural healthcare environments where additional challenges make leading healthcare organizations even more complex. Part of this challenge in effective healthcare leadership is maintaining a motivated and engaged front line workforce within the organization.
There are a multitude of benefits to having more highly motivated frontline employees, many of which are discussed in this dissertation. Employee motivation can be strongly impacted, either positively or negatively, by the leadership qualities possessed by the leaders overseeing frontline employees. A gap in academic research was identified in the field of leadership behaviors related to their impacts on employee motivation in rural outpatient healthcare delivery. Therefore, this qualitative study was developed, conducted, and the data were analyzed to attempt to close that gap in research. This qualitative research study analyzed the leadership behaviors and techniques that are currently employed within the population, as well as analyzed the most effective motivational strategies for employees working in rural outpatient healthcare environments. The study concluded that leadership qualities that are personal in nature and focused on leader- follower relationships are more effective in motivating and driving employees than other factors.
This study also provides guidance for future potential research within this environment to gain an even better understanding of how to overcome motivational challenges faced by leaders in rural healthcare settings.
Keywords: healthcare employee motivation, leadership connections, leadership theory, rural healthcare challenges, outpatient ambulatory care. iv
TABLE OF CONTENTS
LIST OF TABLES ...... vii
LIST OF FIGURES ...... viii
KEY TERMS ...... ix
CHAPTER
I. INTRODUCTION AND BACKGROUND ...... 1 Introduction ...... 1 Topic and Research Problem ...... 2 Ambulatory and Outpatient Care ...... 6 Access to Healthcare in Rural Geographies...... 9 Utilization of Ambulatory Care Facilities to Increase Access ...... 11 Rationale and Purpose of the Study ...... 12 Guiding questions ...... 12 Significance of the Study ...... 12
II. REVIEW OF THE LITERATURE ...... 14 Theoretical Background in Employee Motivation ...... 15 Healthcare Leadership Perspective ...... 25 Intrinsic Motivation of Employees ...... 29 Quality Improvement ...... 34 Low Employee Motivation and Productivity ...... 36 Poor Leadership and Low Morale...... 37 Mitigating Factors ...... 38 Motivation and Change ...... 40 Systematic Improvements Through Motivation ...... 43 Health Policy Impacts on Rural Healthcare ...... 48 Literature Review Summary ...... 50
III. METHODOLOGY ...... 52 Qualitative Design ...... 52 Rationale for the Design ...... 54 Type of Design ...... 55 Researcher’s Role in the Methodology ...... 55 Site and Sample Selections ...... 57 Data Collection Techniques ...... 58 Research Tool Validation ...... 61 Managing and Recording Data ...... 63 Data Analysis Procedures ...... 64
IV. RESULTS AND ANALYSIS ...... 66 Data Analysis ...... 66 v
Analysis Resources ...... 86 Themes ...... 87 Validity and Reliability ...... 88 Summary ...... 89
V. DISCUSSION ...... 90 Summary of Study and Findings ...... 90 Findings Related to Literature ...... 92 Study Challenges ...... 94 Recommendations for Future Research ...... 95 Limitations ...... 95 Summary ...... 96
APPENDICES ...... 98
REFERENCES ...... 115
vi
LIST OF TABLES
TABLE PAGE
1. Summary of Interview Protocol Questions ...... 60
2. Leadership Descriptors ...... 71
3. Components of Effective Leadership ...... 76
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LIST OF FIGURES
FIGURE PAGE
1. Challenges in Rural Healthcare Delivery ...... 4
2. Participation Rate ...... 67
3. Interview Modality...... 67
4. Participation Education Level ...... 68
5. Manager-Staff Interaction Approaches ...... 69
6. Performance Improvement Conversation Delivery ...... 70
7. Performance Improvement Conversation Customization ...... 70
8. Approaches to Developing Employees ...... 73
9. Leaders’ Connectivity with their Direct Managers ...... 74
10. Current State of Teams’ Motivation ...... 76
11. Top Drivers of Motivation (Categories) ...... 78
12. Top Drivers of Motivation (Frequency) ...... 78
13. Top Barriers to Motivation (Categories) ...... 79
14. Top Barriers to Motivation (Frequency) ...... 80
15. Types of Staff Recognition (Categories) ...... 81
16. Types of Group or Personal Recognition (Frequency) ...... 82
17. Described Effectiveness of Organizational Motivation Strategies ...... 83
18. Effectiveness of Manager-Developed Motivational Strategies ...... 84
19. Additional Details and Insight at End of Interviews ...... 85
20. Themes ...... 88
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KEY TERMS
Ambulatory and Outpatient Care Facility: A healthcare center that provides non-emergency care such as care for bacterial infections, imaging services, care for sports injuries and broken bones, etc. These centers can provide care closer-to-home, especially in areas where hospitals may be a long distance away from patients’ homes. The terms outpatient and ambulatory may be used interchangeably (Young, Kroth, & Sultz, 2018).
Rural Populations: Specific population that is being focused on for the research. In the case of this research proposal, it is residents of South-Central, Pennsylvania due to its rural geography
(average population density of 284 persons per square mile) and lack of consistent access to healthcare services in some areas (Pennsylvania General Assembly, 2010). The population density of 284 persons per square mile is below the threshold of 500 persons per square mile to be deemed rural under Medicare reimbursement standards (RHI, 2019).
Health System: A health system is an organization that provides a wide range of professional medical care. These care services can include primary, secondary, and tertiary care as well as hospitals, outpatient care, specialty services, and community health services (Sturmberg, 2018).
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CHAPTER I
INTRODUCTION AND BACKGROUND
Introduction
Employee motivation in healthcare is a component of leadership that is important to have a strong understanding of, as it impacts nearly all aspects of a healthcare facility or organization.
Motivation is defined as motives that are the driving force behind the psychological reasons to engage in a specific behavior (Hitka, Lorincova, Gejdos, Klaric, & Weberova, 2019). Leaders have an ability to impact employee motivation through their communication, sincerity, involvement, and persuasion, among other traits (Empson, 2019; Cook & Artino, 2016). While each and every leader has their own unique leadership style, some of the most predominant leadership styles in healthcare are transactional leadership, transformational leadership, servant leadership, and adaptive leadership (Sola, Badia, Delgado, Campo, & García, 2016). It is possible for some leaders to exhibit behaviors comprising one or more leadership styles, but generally speaking, most will exhibit behaviors consistent of a major theoretical style (Zhu &
Zayim, 2019). Leaders also have the ability to impact organizational culture within the healthcare facility, hospital, or organization that falls within their scope of oversight.
Organizational culture is comprised of an organization’s structure, collective values, and norms and how they contribute to “the way things are done” within an organization’s environment
(Galdikiene et al., 2019). Without motivated employees and a healthy organizational culture within an organization, the organization as a whole will be less efficient and less productive; therefore, it is imperative that leaders, at all levels of an organization, have a strong understanding of effective leadership in order to have a positive impact on the organization
(Hitka et al., 2019). 1
Topic and Research Problem
Access to healthcare services in rural areas in America can be a large and difficult issue to analyze. Many rural geographies suffer from lack of hospitals, primary care practices, specialty services, and other services that are crucial to maintaining healthy populations (Cyr,
Etchin, Guthrie, & Benneyan, 2019). In these rural geographies, patients oftentimes must travel long distances just to reach emergency care, or potentially travel even farther to reach a primary care doctor for routine visits. Therefore, rural patients may forego receiving medical care for non-life-threatening issues due to the geographic boundaries and restrictions. This can result in medical conditions becoming worse over time, resulting in a true emergency at a later time.
Rural healthcare services in the US face a multitude of barriers and challenges such as access to care, comprehensiveness of care services, aging populations, funding for new facilities, recruiting quality clinicians, and leadership and employee engagement issues (Bish & Kenny,
2015; Williams & Cutchin, 2002; Wright, 2009).
Because rural areas have lower population density per square mile (less than 500 persons per square mile per CMS standards), it results in a smaller number of individuals who would utilize a new healthcare facility if it were to be built in a rural area (RHI, 2019). Therefore, it is a difficult challenge for health systems to analyze solutions to providing more access to care when the patient utilization and resulting insurance reimbursement may not be enough to cover the costs of the facility and staff. Therefore, oftentimes more economical routes are explored. For example, ambulatory care facilities have been becoming more popular in the US healthcare system (Sonis, 1998). These facilities can provide care that is more advanced than a regular doctor’s office, but not necessarily to the level of an emergency department (Maddula, Adams, &
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Donnelly, 2018). Therefore, ambulatory care facilities can serve broader populations of people, while using a smaller space than building an entirely new hospital or medical center campus.
In addition to the facing geographical challenges in rural healthcare delivery, organization within which this research is proposed to take place is also facing challenges motivating current employees and creating a more highly engaged workforce. According to a leader within the health system, with whom a personal interview was conducted, employee motivation, engagement, and satisfaction in outpatient centers within the health system have a great deal of room for improvement. While improvements have been made in recent years, there is still room for improvement and strategies need to be developed and/or refreshed in order to mitigate the problem appropriately (Administrator, Personal Interview, 2020). This leader discussed that managers at all levels in the organization should be focused on making as much of an impact on employee motivation, engagement, and satisfaction as they possibly can as motivated employees have a positive impact on every aspect of the organization. While there are a compendium of challenges impacting the delivery of healthcare to rural populations, as outlined in Figure 1, this research is proposed to help fill a gap in knowledge in the specific area of leadership and employee motivation within rural healthcare delivery settings. After an exhaustive literature review, detailed in Chapter 2, it was identified that a research study of this kind had not been conducted before; therefore, this study is a novel research opportunity.
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Challenges in Rural Healthcare Delivery
Access to care Comprehensiveness of available services Aging populations Proposed Funding for new facilities Research Focus Leadership and employee motivation
Figure 1. Challenges in Rural Healthcare Delivery (Bish & Kenny, 2015; Williams & Cutchin, 2002; Wright, 2009).
Employee motivation is comprised of a specific employee’s individual motives, which are elements of personality that stimulate human activity to achieve a certain goal (Hitka et al.,
2019). Additionally, these motives are the driving force behind the psychological reasons to engage in a specific behavior (Hitka et al., 2019). Motivation itself is a permanent process of combining these factors to establish the level of direction and efforts applied to achieving a specific goal in the workplace (Hitka et al., 2019; Khusainova, Jong, Lee, Marshall, & Rudd,
2018). As humans, individual employees have a very basic goal of mastering themselves and their work environment, and will develop personal perceptions of the status of that goal over time (Cook & Artino, 2016). The value that employees place on such goals can be objectively valued, such as salary or achieving mastery of a skill, or they can be subjectively valued, such as feelings of happiness or pride after achieving the goal (Cook & Artino, 2016).
Leaders can have a dramatic impact on employee motivation through the connections that they share with their respective employees. From a theoretical perspective, such as from
Maslow’s Hierarchy of Needs, motivation can be changed and influenced through stimulating internal self-efficacy, self-actualization, and providing challenging work to employees
(Edmonds, Hoops, & Schreffler, 2018). A more modern and better-tested theory of motivation than Mazlow is Vroom’s expectancy theory. Through Vroom’s expectancy theory, Edmonds et
4 al. (2018) indicate that employees can be more effectively motivated if they believe that additional effort exerted will result in a higher level of performance or success. Connecting with employees and rewarding extra effort as such continues to solidify employees’ individual beliefs that their additional efforts will truly result in higher performance and the appropriate rewards that come from that performance. Being rewarded for extra effort, and being perceived as adding value to the organization, results in employees who exert much more effort to be proactive and driven in their roles (Cook & Artino, 2016; Sola et al., 2016).
Individuals in leadership roles in healthcare also have an obligation to the employees reporting to them to ensure that specific jobs, job descriptions, and job expectations are adequately designed in order to ensure that the employees fulfilling those jobs remain engaged and motivated in the organization (Edmonds et al., 2018). In addition to adequately designed jobs, leaders must ensure that the organization provides things such as comprehensive benefits, equitable pay, and appropriate rewards for positive performance in order to maintain a workforce within the healthcare facility that feels appropriately supported (Edmonds et al., 2018). While leaders have an obligation to ensure that individual roles are designed adequately in the organization, the people filling those roles also require support, attention, and feedback. Two- way communication and clear feedback have historically been shown to be key factors in ensuring that employees’ performance is recognized, and to also continue to grow each employee’s efficiency and motivation as an individual (Edmonds et al., 2018). Employees are more likely to respect a leader’s feedback when the leader is perceived as influential, socially astute, and sincere in their communication (Empson, 2019). According to Cook and Artino
(2016), an employee’s success or failure at completing a specific task or achieving a specific goal depends on the employee’s internal perception of their own capabilities. If communication
5 pathways are open between leaders and employees, leaders can effectively provide feedback and support and grow employees’ motivation, skills, and capabilities in the workplace, and at the same time, employees’ perception of their own capabilities in the workplace (Opran, 2018).
Communication between leaders and followers that is perceived by the follower as enthusiastic and truly genuine is most effective in inspiring and increasing confidence in employees
(Empson, 2019; Cook & Artino, 2016). Healthcare leaders who are effective and sincere in their communication, and those who bolster and grow their employees’ capabilities, are the most effective at increasing morale and motivation in the organization as a whole (Empson, 2019;
Cook & Artino, 2016).
Ambulatory and Outpatient Care
Population health is an aspect of healthcare that that aims to improve care in many facets
(such as access and quality) in a certain group of individuals or geographic area. In many areas, such as rural and lower-income areas in the US, access to healthcare can be a challenge. This is because hospitals may be a significant distance away, and there may not be a large pool of primary care doctors to choose from in the given geographic area. According to Wallace (2014), the overall goal of population health should be the improvement of health in an overall population. It is important to focus on these areas through increasing access to care in order to ensure that the health of the rural populations is able to be supported with proper, safe, and effective care. According to Hibbard (2016), ambulatory care centers focus on the needs at hand
(i.e. in an urgent care setting), so the center’s providers can treat, educate, and coach the patient and the patient’s family. However, these centers do not provide 24/7 medical attention or monitoring, nor do they serve as primary care practices (Hibbard, 2016). Therefore, these centers are able to provide care levels and services that are “in between” a primary care practice and a 6 hospital emergency room. Additionally, according to Hibbard (2016), statistics are increasingly becoming more important in managing population health by identifying types of health services that are lacking in a given geographic area, and therefore can support the development or addition of services specific to the needs of the area being studied.
With population health and health improvement initiatives being negatively impacted by the lack of access to care in certain geographies, such as rural areas, this is an area of importance for research. Improvements in access to care in a specific area not only create easier routes for individuals to seek and receive care, but they can also positively impact the population health initiatives in that given area as well. According to Hibbard, Greene, Sacks, Overton, & Parrotta
(2017), ambulatory care facilities can be studied in conjunction with a population health initiative, such as heart disease management and treatment, in order to identify if an ambulatory care facility would benefit a specific population. Another population health initiative that can be assisted through the development of ambulatory care facilities is the prevalence of HIV in specific populations (Riley, Moore, Haber, Neilands, Cohen, & Kral, 2011). Instead of going to an emergency room for minor injuries or non-life-threatening ailments, patients can be treated at ambulatory sites at a lower cost and with less of a burden on the overall health system (Hibbart et al., 2017). Additionally, patient choices regarding where they seek medical care, particularly in rural areas with limited access, can be key determinants in health outcomes for that population
(Hibbart et al., 2017).
According to Busby, Purdy, & Hollingworth (2017) and Mitterlechner et al., (2018), areas categorized as rural often have less primary care practices and also longer distances form patients’ homes to the closest hospital locations. Individuals from these areas, who may not have a primary care doctor, could end up incorrectly utilizing the emergency room or hospital for non-
7 emergency needs simply due to the lack of access to care. Additionally, this is a challenge that is not a focus of one stakeholder; instead, it is a focus of population health initiatives as well as health systems that have the expertise to implement more options for care (Busby et al., 2017).
Ambulatory care facilities, oftentimes developed by hospital systems, can be introduced in rural areas in order to provide care in a more efficient and cost-effective manner for these rural populations instead of the emergency departments being improperly utilized.
Health systems are often made up of multiple service lines and stakeholders, meaning that different components of the system rely on each other. According to Katerndahl, Wood, &
Jaen, 2017), physician offices often rely on hospitals to treat patients that cannot be treated in a doctor’s office. However, ambulatory care facilities can serve as a more highly-skilled facility to handle complex cases without the need for them to burden resources in a hospital setting
(Katerndahl et al., 2017). Similarly, Haas (2016) discusses that no two ambulatory care facilities need to be identically the same. Ideally, new ambulatory care facilities can assist in improving access to care by catering their services to the needs of the population who will be served by the facility (Haas, 2016). In the cases of rural areas with lack of access, these facilities can focus on providing more advanced services as a non-emergency alternative to using the emergency room unnecessarily. This improves not only access to care, but can provide more efficient care to those individuals and contribute to positive impacts in population health at the same time. Caldwell,
Ford, Wallace, & Wang (2016) discuss that urban residents generally have more choice when it comes to their healthcare, and rural areas may only have one hospital and one office for a given specialty. Therefore, increased access to care can give rural residents more choice in their healthcare, and also prevent the longer drives to receive basic care services (Caldwell et al.,
2016).
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There are many barriers that can prevent healthcare organizations from developing facilities to provide care in rural areas, or areas that have a lack of access to quality care in general. According to Dileio et al. (2015), two of the primary barriers to facility development in rural areas is the lack of access to talented individuals to serve as administrators, as well as the financial burden that the facilities pose while they may be underutilized. This ties in with a similar point discussed by Leslie, Sun, & Kruk (2017), which is the idea that, even if funding is available to build a facility in a rural area, it should not be built just to build it. If there are not qualified clinicians and administrators to provide services in the facility, and ensure that the care will truly be quality care, then the proposed facility is not a sensible project for the organization
(Leslie et al., 2017). When analyzing the potential access to care that ambulatory care centers can provide in rural areas, quality of care is one of the most important aspects to focus on when seeking to improve population health in a specific geographic area according to Bezad et al.,
(2011). A theory discussed by Khanassov et al., (2016) involves strategizing to provide rural residents with the right care, at the right place, at the right time, as the guiding force behind improving population health via access to care for a specific population.
Access to Healthcare in Rural Geographies
Accessing healthcare in rural areas in the United States continues to lag behind access to care in other geographies, such as urban and suburban areas. Even though rural populations can be considered small due to the population densities, at least 60 million individuals in the US live in areas considered to be rural, all of whom will end up needing healthcare at some level during their lives (Wright, 2009). According to Vaughan, Welle, Ridenour, and Mueller (2018), and
Basanta (2002), access to quality care facilities and clinicians decreases as geographic population density decreases and geographic isolation increases. Some of the components of this disparity 9 are in primary care access, emergency care access, and specialty care access. This is an important issue to continue to study as the lack of access to care can prove to be detrimental to health outcomes in these rural areas. If patients live long distances from even basic services, such as primary care, they may be less inclined to have their annual screenings and testing done to avoid major health events occurring later in life (Pierce, 2007). According to Pierce (2007) and
Vaughan et al. (2018), lack of health infrastructure as well as socioeconomic disparities can serve as large barriers to advancement of healthcare in rural areas. Pierce (2007) indicates that developing an in-depth understanding of the challenges in rural healthcare sectors is equally as important in policy development at all levels, as well as the service delivery perspective from healthcare organizations.
The research completed by Pierce found that individuals who lived more than ten miles from their primary care physician were much less likely to go to their physician at all compared to patients who lived within ten miles from their primary care physician’s office (2007). In a similar perspective to Pierce’s research, Koller et al. (2010) also determined that access to care in rural areas is not stymied by only one barrier. Aspects such as distance, location, and even aesthetics of healthcare facilities can prove to be barriers to receiving healthcare in rural areas in addition to the barriers surrounding policy developments in those same exact areas (Koller et al.,
2007; Pierce, 2007). Additionally, provider supply, the distribution of facilities geographically, and retention of qualified clinicians have all served as detriments to advancement of rural healthcare in the past and continue to do so today (Williams & Cutchin, 2002). Therefore, there are many different barriers to advancing ambulatory care facilities and access in rural areas, and policymaking is just one component of removing some of those barriers to access. Policymaking and the development of new policies in healthcare has the opportunity to open new doors to
10 access to care in rural areas, and while there are many barriers to accessing care in rural areas, policy development or changes can prove to be an important first step in that process as a whole
(Koller et al., 2010).
Utilization of Ambulatory Care Facilities to Increase Access
According to Simmons, Huddleston, Morgan, and Feldman (2012), some of the largest disparities between urban healthcare availability and rural healthcare availability can come from the lack of a physical presence of healthcare facilities. Because rural areas are less-densely populated, there are oftentimes simply far less facilities in those areas in general compared to more densely populated urban and suburban geographies. According to Moller, Christiansen,
Bell, Fredburg, and Vedstsed (2018), a technique that is growing in popularity in rural hospitals is to develop outpatient ambulatory care clinics. These clinics allow for a more comprehensive set of services to be provided in a rural geography than patients can find in a regular primary care physician’s office (Moller et al., 2018). While these facilities would not necessarily provide care for life-threatening conditions, the facilities would prevent patients in rural areas from having to drive long distances to emergency rooms when their primary care physicians’ offices are closed
(i.e. after hours). Additionally, Moller et al. discussed that the development of these new facilities in underserved areas reduced the number of patients presenting to emergency rooms with conditions that were not severe enough to be in an emergency room. Policies supporting these types of developments in rural areas can prove to be more cost-effective than funding and building entire hospital campuses, and can provide a much-needed central location for rural patients to seek care when needed, while also having care closer to their homes.
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Rationale and Purpose of the Study
Because of the large population that outpatient care clinics traditionally serve, and the increased access to care these clinics afford to patients who may be far away from large hospitals, it is imperative that outpatient care facilities operate as effectively and efficiently as possible. Developing and maintaining a motivated workforce, dedicated to providing high- quality care to the served populations, will allow for continued positive impacts to be made on those populations into the foreseeable future. As discussed previously, both developing and maintaining motivated workforces in healthcare are large and daunting challenges for healthcare managers and leaders, at all levels, to take on. Due to the lack of current research in the field of outpatient care, and these challenges continuously faced by leaders, a research case study into the specific aspects of leadership styles and behaviors and their respective impacts on frontline employee motivation is proposed to help bridge the gap in knowledge and literature.
Guiding Questions
In order to better understand the impacts that specific leadership traits have on the motivation levels of frontline employees in outpatient care clinics, a specific research question is posed to guide the project. The research question that will guide this proposed dissertation case study is: What leadership behaviors and leadership styles are most effective in developing a motivated frontline team in an outpatient care service line within a health system serving a rural geography in South-Central Pennsylvania?
Significance of the Study
Due to the present gap in research and literature focused on employee motivation in outpatient clinical settings, a research case study is necessary to help understand this concept.
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This proposed research has the potential to impact leaders at any levels within the organization where the research is being conducted, as well as leaders within other organizations that provide a similar service. The research will also contribute to the field of study by broadening the scope of research on employee motivation and into outpatient clinical settings as opposed to more hospital-based research which dominates the literature currently published. Additionally, the research is practically applicable due to the current state of employee motivation within the health system where the research will be conducted, as evidenced by the aforementioned interview with a leader within the health system. Therefore, this research has the potential to have a significant impact to the scientific, academic, and operational aspects of healthcare, as well as develop recommendations for future research at the conclusion of the study. The research case study will provide a framework for future research endeavors to use as a foundation as well.
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CHAPTER II
REVIEW OF THE LITERATURE
The topic that will guide this research is employee motivation in healthcare, and the psychological relationship between leaders and followers. More specifically, a focus will be placed on primary drivers and outcomes from highly-motivated workforces in healthcare. Also, different leadership styles and their respective relationships with followers can have an impact, positively or negatively, on overall motivation in the healthcare industry. Higher levels of employee motivation can produce a more productive workforce, which in healthcare can lead to a higher quality of care provided by those employees. It is important for leaders to be connected to their teams in order to ensure that the highest quality of care is being provided at any given time in the organization.
This literature review is organized primarily in a thematic format. The thematic format focuses on grouping similar thoughts together by specific themes, topics, or major issues
(Roberts, 2010). This approach also requires a great deal of synthetization between comparable sources. Much of the research that has been conducted to date can be grouped into theoretical backgrounds, the perspective of the leaders on the issue of motivation, intrinsic motivation of employees, and finally the impacts on quality from motivated employees. These are also the same four primary themes utilized in the annotated bibliography. Within this thematic approach, the theoretical section will also be set up somewhat chronologically. This is because there are widely-known and studied leadership theories, which are generally older and historical, and then there are also more current and modern leadership theories. The research done to date incorporates both historical and modern leadership theories; therefore, it will provide a cleaner final product to organize the theoretical section chronologically.
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Theoretical Background in Employee Motivation
Many theories of management and leadership apply to the issue of employee motivation in healthcare settings. Throughout history, many theories, in both management and leadership, have been developed and re-developed as workforces continue to change and modernize. For this research, in order to maintain a focus around the research question, servant leadership and transformational leadership will be the primary focus areas for theoretical comparison.
First, servant leadership is an approach that has been linked with producing patient- centered and high-quality care within healthcare settings, according to Aij & Rapsaniotis (2017).
Servant leadership is a leadership style that is becoming more prevalent in healthcare management structures as workforces in the field continue to change and modernize, and it is a relatively modern theory developed by Greenleaf in the 1970s. According to Aij & Rapsaniotis
(2017), servant leadership involves leaders who are serving their followers as much as their followers are serving them or the organization, which can lead to a more highly engaged and motivated workforce. This theory is slightly different from other leadership theories as most other theories focus on leaders’ actions in their roles. However, servant leadership, as a categorization of people, involves analyzing leaders’ personal character and willingness to truly serve their followers (Aij & Rapsaniotis, 2017).
There are many characteristics that theorists include in the categorization of servant leadership. Servant leaders in healthcare organizations often have goals of building sustainability within an organization, and also to serve the community (i.e. the community around a hospital) at the same time (Aij & Rapsaniotis, 2017). Another key trait of a servant leader is the ability to bring out the best in people, specifically those who work for the servant leader. According to Aij
& Rapsaniotis (2017), servant leaders who instill servant-like qualities in an organization will
15 build an organization that is focused on: valuing people, developing those people, building a community, displaying authenticity, providing goal-oriented leadership, and sharing leadership power with others in the organization. Because healthcare is “caring” in nature, servant leadership theoretically fits well with the model in inherently being servants toward patients and patient outcomes (Garber, Madigan, Click, & Fitzpatrick (2009). All of these aspects together create a transparent and accountable organization while also including many employees in the decision-making which can increase motivation of those employees involved in the servant leadership structure.
In most theories of leadership or management, there are specific “tools” that different types of leaders utilize in order to perform their job duties within that particular leadership theory. However, servant leadership is slightly different in the aspect of tools. Instead of using a highly structured methodology when approaching decision-making (i.e. Lean methodology), servant leaders instead rely on their own intuition, characteristics, and the underlying service to others, in order to guide them through decision-making processes (Aij & Rapsaniotis, 2017).
This usage of character and service can influence how followers view servant leaders as well.
According to Garber et al. (2009), servant leaders who exude collaborative behaviors in the workplace are viewed as producing a higher quality of work from the viewpoint of peers and subordinates in the healthcare environment. Additionally, the authenticity that servant leaders display in interactions with followers or direct-reports allows for a higher level of trust to be built within the team itself, and within the organization as well. According to Garber et al. (2009), nurses in healthcare environments rank those authentic relationships as a strong component of achieving high quality care within the department. Nurses and physicians report that collaboration in healthcare environments can have a strong impact on patient success outcomes;
16 this collaborative environment can consist of teamwork, common values, a desire to learn from and teach others, and working in harmony with one another (Garber et al., 2009).
Garber et al. also explain that there is a gap in research comparing servant leadership to quality outcomes, which supports the needs for this proposed research study. Even though servant leadership theories were introduced in the 1970s, most research since then has been focused on developing tools to measure servant leadership, which has proven difficult due to the basis that servant leadership is founded on character and integrity, which are not as easy to quantify as other leadership and management theories (Garber et al., 2009).
A second theory that is being analyzed in this proposed study is transformational leadership. The transformational leadership style emerged in the same era as servant leadership as well as alongside authentic leadership and situational leadership (Jambawo, 2018). Nielsen &
Daniels (2016) indicate that transformational leadership, due to its popularity in healthcare and its modern approach, is one of the most widely-researched leadership theories in practice. At its core, transformational leadership involves leaders who motivate their subordinates to achieve common goals across the team (Jambawo, 2018). This is a leadership style that allows managers and leaders to induce change in a specific team, department, or an organization as a whole. A similarity that transformational leadership has with servant leadership is that it involves treating subordinates with dignity and respect. This is very different from more traditional leadership such as transactional leadership which focused on the hierarchy aspect of management. Jambawo
(2018) indicates that transformational leaders must hold themselves to a standard that allows them to lead by example, and to make changes within a department or organization by motivating and empowering those who work for them.
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Additionally, transformational leadership traits involve individuals who seek to not only motivate those who work under them, but also to improve the performance of followers as well as supporting them to develop to their fullest potential (Jambawo, 2018). With regards to motivation of teams in healthcare, transformational leaders have proven the ability to increase teamwork, increase the quality of patient care and patient experiences, as well as retain highly motivated employees on their teams (Jambawo, 2018). According to Nielsen & Daniel (2016), transformational leaders are able to encourage group identity of teams, as well as serving as a role model who leads by example in the environment. Quality of care if oftentimes influenced by the commitment and engagement of staff who are caring for an individual patient. According to
Jambawo, leaders who utilize transformational styles in healthcare settings can develop more engaged and highly motivated clinical staff than other leadership styles (2018). This motivation can be achieved by the leader working not necessarily as a traditional hierarchical or “top down” leader, but more as a coach, mentor, or teacher with an end-focus of improving their followers’ work performance.
Compared to more traditional leadership, such as transactional styles which focus on systems and processes, transformational leaders have an obligation to their followers inspire and motivate them to move toward a shared vision with the rest of the team (Jambawo, 2018).
According to Jambawo, one of the largest strengths of using transformational leadership in healthcare settings is that it is an opportunity to advocate for positive change at multiple levels within an organization, or even at the department and team level (2018). This style also puts a great deal of focus on future growth and planning. These goals for future growth, changes, or developments serve as visions for leaders to motivate their team to move toward (Jambawo,
2018). Instead of focusing simply on a process or policy in the moment, transformational leaders
18 engage their followers and encourage future growth and progress toward those goals (i.e. departmental goals or organizational mission statements and goals) (Jambawo, 2018).
Transformational leaders engage their followers to move toward a shared vision and goal through creating a mutual group understanding and a shared social identity for the group which is likely to influence norms and behaviors within that team (Nielsen & Daniel, 2016).
Within the field of leadership, there are a plethora of theories and frameworks that apply to different management styles and interpersonal leadership styles. These theories, some historic and some more modern, provide clear tools to gauge what type of leader an individual is, and also which types of leadership styles will work best in certain situations given the organization’s current state and needs. According to Rahbi, Khalid, & Khan (2017), building effective leaders in a healthcare organization, who understand the theoretical components of their roles related to success, will drive the organization toward higher levels of team motivation and a more positive work culture. Similarly, Cogin (2016) indicates that management matters when it comes to either being successful in delivering quality healthcare or failing to do so. In order for an organization to move forward in a positive direction, there must be strong and competent leaders in place throughout the organizational structure.
Leaders in the healthcare industry are frequently, and almost consistently, faced with the challenge of improving employee relations in a specific target area (Cogin, 2016). These areas can be related to employee motivation, employee productivity, or another similar area of employee relations within the organization. Cogin (2016) discusses that employee motivation is a challenge that, while faced by most leaders in the industry, is also the most closely linked priority to quality improvement within healthcare facilities or organizations. This priority is clear due to the necessity to include employees in almost any quality improvement effort; therefore, a
19 more highly motivated workforce may be more receptive to process changes surrounding quality improvement. The relationship between leaders and followers, in the context of improving employee motivation, must contain a high level of trust and empowerment in order for new improvement initiatives to be received positively and for those initiatives to be successful over time (Cogin, 2016).
Maslow’s hierarchy of needs is a behavior theory that is very widely known in the leadership field. It serves as the basis for many corporations’ training protocols and associate relations procedures. Benson & Dundis (2003) indicates that Maslow’s hierarchy of needs is an aspect of leadership that can be beneficial in creating clarity during healthcare organization changes such as mergers or expansions. Two of the components of Maslow’s hierarchy that leaders often focus on are stress levels and self-actualization (Benson et al, 2003). Managing an organization through a large change is a huge undertaking for leaders at all levels; however, leader-follower relationships still need to be retained regardless of any changes that are occurring internally within the organization. Benson (2003) discusses that, in order for leaders to successfully motivate employees to persist through a large organizational change, the leaders must focus on “making the employees feel secure, needed, and appreciated” within their respective roles. While organizations are ever-evolving, so are leaders’ responsibilities to those organizations. However, if leaders continue to focus on the individual needs of their respective followers, a much more highly motivated workforce will result from that leader’s efforts.
Leaders of organizations not only need to understand the importance of employee motivation, but must also be competent in ways to measure that very motivation. Because employee motivation is a psychological factor, it is not an incredibly easy factor to gauge or measure within individual employees or teams. Generally, job satisfaction is measured through
20 focusing on the job itself and the environment in which the employee performs that job (Beyazin,
2017). According to Labiris (2008), Maslow’s hierarchy of needs is also a theory that can be utilized as a measuring tool to measure employee motivation. In an instrument developed by
Labiris for an academic research study, Maslow’s theory was combined with Herzberg’s hygiene theory to create a more well-rounded measurement tool to use within the hospital organization
(Labiris, 2008). Herzberg’s original study utilized six “motivators” which were achievement, recognition, advancement, work, growth, and responsibility (Labiris, 2008). Labiris also indicated that, using pieces of Herzberg’s theory, that hygiene factors could be used as a measurement (2008). This is a relevant measurement aspect because when the hygiene factors are lacking within an individual’s respective job or environment, it results in that individual being less motivated. Hygiene factors can include salary, interpersonal relationships, supervision, policies, and job security (Labiris, 2008). Therefore, a successful measurement tool to measure employee motivation will aim to clearly measure motivating factors as well as hygiene factors in order to have the most comprehensive results as possible with the individual measurement tool.
Several different styles of leadership are common in the healthcare industry. These styles can vary by person, organization, or geographical area. According to Choi (2016), healthcare has historically been dominated by individuals possessing a transactional leadership style. However, as the healthcare field continues to evolve, so do the leaders and leadership teams. In more modern history, transformational instead of transactional leadership has been utilized within hierarchies in healthcare organizations (Choi, 2016). Transformational leadership theories not only work well with ever-changing regulations and requirements in the healthcare field, but they can also do a great deal to enhance empowerment of employees (Choi, 2016). Empowerment is a strong component of motivate employees, and when employees are empowered to make
21 decisions and be proactive, they have a higher job satisfaction level and higher motivation levels
(Choi, 2016).
Another leadership theory that has been strongly linked with a more highly motivated staff is the theory of servant leadership (Newman, 2017). Servant leaders, who are ones that integrate themselves on the same level as their followers, have been shown to produce more satisfied and engaged followers and teams of people (Newman, 2017). Servant leaders put their followers first, develop relationships with their followers, and help their followers to grow and succeed (Newman, 2017). Similar to how transformational leadership can encourage empowered employees (Choi, 2016), servant leadership can create employees who are more likely to go above and beyond their basic daily job requirements (Newman, 2017). Psychological empowerment, specifically when present in high amounts can result in a team of healthcare employees who are more highly productive, more motivated to take proactive action in favor of patient satisfaction, and will complete tasks outside of their job description without necessarily being directly asked to do so (Choi, 2016; Newman, 2017). According to Newman (2017) servant leadership and transformational leadership are very similar theories; however, servant leadership weights more heavily on investment in the followers’ success than does the transformational leadership theory. Servant leadership also has a focus on making a contribution to society as a whole whereas transformational leadership does not have a focus on that component (Newman, 2017). Leaders serving as role models and coaches, such as those exhibiting transformational or transactional leadership behaviors, are key components in healthcare organizations modernizing and becoming High Reliability Organizations (Karalis &
Barbery, 2018).
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Similarly, Irving discusses that servant leaders are those who pay special attention to ensuring that their followers’ needs are entirely met (2017). This method of management has a simple philosophy of focusing on followers’ needs so that the customers’ or patients’ needs will be equally well-met at the other end of the equation (Irving, 2017). One major difference between servant leadership and transformational or transactional leadership discussed earlier is the idea of where organizational success is derived from. In more traditional transactional or transformational leadership theories, the sole providers of organizational success are from farther up the “ladder” from leaders (Irving, 2017). Conversely in servant leadership, the focus is in the opposite direction; instead, servant leaders see their followers as the sole drivers for organizational success and for the meeting of organizational goals (Irving, 2017). Servant leadership has been strongly linked to higher job satisfaction and organizational performance in the healthcare sector as a whole (Irving, 2017).
A more recently-developed and studied method of leadership is described by Beil-
Hildebrand (2006) as “management by walking about”. While this style does not necessarily have an organized name as the previously discussed theories, it is becoming more popular. This leadership theory is comprised of more informal relationships between senior executives in the hospital or organization (i.e. the chief executives) and all of their direct-report staff and frontline staff (Beil-Hildebrand, 2006). More modern organizations are adopting this method of management which can be seen as leaders who are out of their office walking around the hospital and interacting with the “real world” and not just the higher-level thinking interactions (Beil-
Hildebrand, 2006). This relationship allows followers to have much more trust in their leaders when those leaders are actually seen and spoken to in person; this dialogue, even if brief and informal, can connect much better with younger and more modern workforces than older
23 leadership theories (Beil-Hildebrand, 2006). Spontaneity is also an aspect of this modern approach. For example, a leader may shadow a department unscheduled, or sit in on a department meeting just to hear different points of view (Beil-Hildebrand). This leadership method is still relatively new compared to more traditional leadership theories, therefore there is only a small amount of research completed on the topic.
In summary, there are a large amount of theories, some widely known and some relatively new, that are relevant to successful leadership in healthcare. More historic and conventional theories, such as transactional leadership, are applicable in situations that require less complex management. More modern leadership theories such as transformational leadership are relevant in healthcare organizations that are undergoing changes. Within healthcare, quality is always a key differentiator in a highly competitive market. Therefore, leaders must be able to connect properly with their teams and with their organization as a whole in order to ensure that quality improvement is consistent across the organization.
Guclu & Guney (2018) also discuss that low levels of motivation can have detrimental effects on the productivity of a specific staff member, team, department, or an organization as a whole. Low levels of motivation create two issues in workforces. Unmotivated employees develop an apathetic approach to work, and are therefore unwilling to complete some or all tasks that are expected of them (Guclu & Guney, 2018). Additionally, unmotivated employees have a lower level of overall productivity as discussed earlier (Guclu & Guney, 2018). These aspects together foster an environment where employees in healthcare may not be following protocols appropriately, or using resources (i.e. systems, time, supplies, etc.) appropriately or in the best interest of the patients being seen.
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Conversely, while there are many aspects of management that can result in low motivation, there are also similar aspects of those leadership styles that can create higher levels of motivation. The aspects of manager-employee connectivity and intrinsic motivation as discussed earlier are two components that are important for leaders to focus upon. When employees are motivated and driven, it is up to their managers to help those employees build off of those strengths. According to Zenger & Folkman (2018), there are several traits of motivated and productive employees that managers can build off of. Some of these traits or actions are setting goals, showing consistency, having knowledge, driving for results, anticipating problems, taking initiative, and being a collaborative employee (Zenger & Folkman, 2018). Strong leaders and managers should be able to, through a leadership theory such as servant leadership or transformational leadership, identify these traits in their employees. If a manager is able to individually identify these traits (some or all) in their employees, they can better determine how those employees are effectively motivated intrinsically. Employees cannot necessarily all be managed exactly the same way—this is where transformational leadership or servant leadership can come into play to be utilized in order to individually manage each employee to be the best that they can be. Transformational leadership and servant leadership are similar in this aspect, as discussed earlier, in that both theories seek to develop and grow employees to perform at their highest level possible.
Healthcare Leadership Perspective
From the leadership perspective, individuals holding management, senior management, and executive roles within organizations can have a great deal of influence and impact on those who work under their management. Within organizational behavior theories, there are many different styles of leadership that can be used to describe different leaders’ leadership tendencies 25 and preferences. Transactional (or more traditional) leadership has historically been the primary leadership style within the healthcare industry (Choi, 2016). However, in the modern ever- evolving field of healthcare, transformational leadership has come into play much more frequently. According to Choi (2016), transformational leadership has been shown to be related to a positive increase in employee motivation and job satisfaction within the healthcare sector.
Within healthcare organizations, highly motivated staff is a key component of performance, and at the same time it is the most difficult aspect of an organization to successfully manage
(Beyazin, 2017). The ability to motivate employees is a very basic requirement of successful leadership in a healthcare organization (Sulliman et al, 2009). If a hospital organization begins to lose staff due to low levels of motivation, and low levels of job satisfaction, it can be crippling on every aspect of that organization (Beyazin, 2017).
Motivation is frequently analyzed, both inside and outside of the healthcare industry, from the perspective of followers being motivated by leaders or other variables. However, an aspect of motivation that is less focused on in the academic and practical world is the motivation behind why leaders choose to lead. There has been much less research completed surrounding the topic of intrinsic and external motivation of leaders, and what motivates them to perform well, motivate their teams, and achieve professional and personal goals. According to Mascia
(2015), there is a gap in research surrounding leaders’ motivation to lead within organizations, and this gap is rarely studied by looking at personal characteristics of individual leaders. An individual leaders’ motivation to lead is comprised of decisions to assume training in leadership positions, to accept leadership roles, and to make conscious decisions surrounding the intensity and persistence while being a leader (Mascia, 2015). Individual (i.e. internal and personal)
26 motivational factors within a person are key drivers in the process of individuals’ movement from professional to management positions within healthcare (Mascia, 2015).
Internally, leaders can be motivated to lead productive teams through self-efficacy which is part of the social-cognitive theory (Mascia, 2015). Self-efficacy is one’s belief that they either can or cannot complete a particular task (Mascia, 2015). With regards to leadership positions, this applies when a healthcare professional is in the process of making a decision as to whether or not to move into a leadership position in the organization. The environment that a leader works within can have an impact on their perception of a new role as well (Mascia, 2015). For example, if an individual works within an organization that has a culture of career growth and support, that individual will have a better understanding of what the new potential role entails, and also will have the support to know whether or not they are suitable for that role (Mascia,
2015). Avelar (2016) confirmed a similar relationship between healthcare leaders, career growth opportunities within an organization, and the motivation to stay within the organization due to potential career growth. In order for an individual to be motivated to lead an organization, or lead within an organization, their beliefs must align strongly with those of the organization. This results in the individual being much more motivated to pursue their own self-interests while also progressing the organization’s interests forward at the same time (Mascia, 2015).
Leaders in the healthcare industry and their respective success goes beyond the pursuit self-interests and can include the interpersonal relationships with their followers. Different leadership styles and theories can result in leaders having differing relationships with their followers or teams. One differing component between leaders and their chosen leadership style is the amount of control they maintain over their followers (Vries et al, 2012). Older and more traditional transactional leadership may focus on controlling followers, while modern
27 transformational leadership styles may focus on empowering individuals to speak their minds
(Mascia, 2015). This voice that leaders allow their followers to have is referred to as the “pseudo voice” within an organization (Vries et al, 2012). Leaders may be motivated by hearing their followers’ input, or they may be more motivated by simply ensuring that their followers complete their basic job duties appropriately (Mascia, 2015). Lam (2016) also indicates that leaders who allow their followers to express their “voice” produce a much more ethical and more motivated workforce as a whole. Because of these connections and open lines of communication directly from the front line to leaders, the overall performance of the department or organization can see a positive impact (Lam, 2016).
Motivating leaders can also come from an external point of view. Just as frontline employees are motivated intrinsically and externally (i.e. by their manager or leader), leaders can also be motivated externally by their leader (whoever is next in the hierarchy of the organization). Suliman (2009) indicated that many healthcare organizations are now offering longevity bonuses to their leadership teams in order to retain them for long periods of time.
While this has been in practice for frontline employees as a motivating factor, it is relatively new to be put into practice at the executive level in order to retain productive leaders within an organization (Suliman, 2009). Avelar (2016) indicated that payments to high-performing leaders can result in a much more focused and collaborative leadership team as a whole. Suliman also discussed that longer-tenured leaders and executives in hospitals have a much higher level of job satisfaction and motivation to lead than newer leaders in the same hospital (2009). Kavanaugh
(2006) conducted a similar study in a hospital organization, and also concluded the same result of longer tenure and its direct relation to job satisfaction among leadership groups in that organization. Kavanaugh also indicated that due to the large amount of change occurring in the
28 healthcare industry fundamentally, it is ever more important to retain good leaders and employees in order to lead organizations to success among those industry changes (Kavanaugh,
2006).
In summary, motivation in healthcare is often studied from the perspective of frontline employees who are motivated by leaders. However, there is another side to employee motivation which is the leadership perspective. Leaders oftentimes are motivated to lead for different reasons that employees are motivated to be in their positions. However, motivation at both levels is equally important. There are many approaches to motivating leaders such as performance compensation and recognition for longevity and tenure with a single organization. Organizations are becoming more and more focused on quality and implementation of new initiatives; therefore, those organizations are beginning to also focus on retaining the successful and competent leaders in order to ensure that the quality and competitiveness of the organization continues to progress forward.
Intrinsic Motivation of Employees
Higher job satisfaction and motivation within health and hospital employees is a well- known component of personnel management that produces a higher level of productivity within employees (Beyazin, 2017). More highly motivated employees also closely relate to higher levels of patient satisfaction from the patients that the employees directly cared for or interacted with within the organization (Beyazin, 2017). Additionally, more highly motivated teams or organizations will have much lower employee turnover rates (Mak et al, 2001). This is due to employees’ investment in their respective working environments through motivation, which has a direct relationship with longevity and remining within organizations for longer periods of time
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(Mak et al, 2001). Conversely, employees’ intent to leave their jobs in the healthcare field is primarily linked to job satisfaction in recent studies (Opollo, 2014).
Employees in the health industry who have low levels of motivation and/or job productivity can create many challenges for the team, the leaders, and the organization as a whole. For example, some challenges that can surface from low motivation levels are: decreased productivity levels, increased on-the-job accidents, internal conflicts between employees, higher employee turnover and replacement percentages, and increased instances of tardiness for work shifts (Beyazin, 2017). Labiris (2008) also discussed that nurses oftentimes present with the highest levels of job dissatisfaction when surveys are completed within healthcare organizations.
This high level of dissatisfaction was also confirmed by Choi, Goh, and Tan (2016) who studied nursing personnel internationally and indicated that nurses had the highest levels of turnover.
Choi et al discovered that organizations with the highest nurse-staff turnover were losing their nurses due to a primary cause which was lack of job satisfaction (2016).
The top two factors in an employees’ job that can drive an employees’ lower motivation levels are the lack of advancement opportunities and lack of recognition from their leader or other leaders in the organization (Labiris, 2008). Conversely, the top two factors in an employees’ job that can drive higher levels of motivation in hospital employees are their actual jobs and roles (i.e. truly enjoying the work being completed), and achievement of goals that were set for that particular team or employee (Labiris, 2008). This is confirmed also by Willis (2008) who also discusses career opportunities being one of the largest motivators in the healthcare industry with financial incentives being another important motivator. Higher levels of motivation within healthcare organizations have been found in organizations that favor an empowerment culture (Choi, 2016). Employees who are empowered to make decisions on behalf
30 of patients, and take ownership of those decisions allows those employees to develop a sense of pride and importance in the jobs that they are performing (Choi, 2016). Nasser (2013) also confirms that employees in the healthcare sector who have more empowerment support from their manager or leader experience a much higher level of motivation than other groups. When leaders exhibit behaviors that support empowerment of their employees, and foster a workplace culture that supports that empowerment as well, it has been shown that intrinsic motivation levels of employees can be positively impacted (Nguyen, 2020).
In addition to empowerment, emotional stability and support can serve as a supporting factor to healthcare employees (Chaudhry et al., 2016). Because employee performance is the key to an organization’s success, it is crucial that organizations invest in their employees to ensure continued success over time (Chaudhry et al, 2016). In order to be most successful,
Chaudhry indicates that factors hindering employee motivation should be focused on at times more than factors that attempt to boost employee motivation (2016). Tension, stress, and pressure are just a few of the emotional components of employee behavior that can hinder an employee’s motivation, and therefore the overall success of that employee. When these emotional barriers are present, they can result in an employee or an entire team becoming disconnected and unsuccessful (Chaudhry, 2016). According to Chaudhry, 60 percent or more of employees in the healthcare sector can be impacted by these emotional factors at any given time
(2016). Wombacher (2014) indicates that emotional instability in healthcare workers can result in inter-team conflicts. While conflicts are not entirely avoidable, especially in larger organizations with more employees, more highly motivated and productive employees and departments will have a tendency to take quicker action to resolve those conflicts and re-focus on the job at hand (Wombacher, 2014).
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Chaudhry (2016) also indicated a similar point as Labiris (2008) which is if a lack of career advancement is present in an employee’s department or organization, it can create a great deal of emotional inequities with that given employee which can result in the lack of motivation due to emotional factors. Hensel (2015) discussed that a tense work environment, while it impacts their emotional stability and motivation, also leads to a much faster rate of burnout in nursing teams in hospitals. In an already fast-paced environment, interpersonal tensions can create an environment that is much less conducive to motivating and retaining productive employees. Opollo, Gray, & Spies (2014) indicated through a study that poor work environments coupled with high workloads will result in low levels of motivation even in individuals who are intrinsically motivated.
Another internal form of internal motivation in the healthcare industry is the concept of goal-awareness (Hawng, Lee, & Shin, 2016). While this seems as a relatively simple concept, it is a concept that is often overlooked from the management perspective in motivating frontline employees. Hwang indicates that goal-awareness is derived from the historic McClelland’s Need for Achievement Theory (Hwang et al., 2016). Employees who are highly motivated by achievement wish to receive feedback from their leader pertaining to how well they are performing in their job duties (Hwang et al., 2016). Conversely, employees who are not motivated by achievement, and therefore have a low goal-awareness level, are primarily motivated by how their leader feels about them and less about how well they are performing their job functions (Hwang et al., 2016). Individuals who are goal-aware and highly motivated by achievement should have goals set for them by their leader, or the leader can share with them overall organizational goals that the employee can help to achieve.
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Intrinsically motivating employees can also be targeted with investment in programs and initiatives that are beneficial to employees outside of standard health insurance benefits. These types of programs can show employees that the organization is focused on their wellbeing
(Zivin, 2017). This investment can be programs such as such as internet-based healthy exercise programs, or in-person competitions and weight-loss classes (Zivin, 2017). If the topics of the campaigns are of interest and of use to the employees, the employees will feel more connected with their peers as well as with the sponsoring organization. Wellness campaigns such as these can also have positive impacts on the company as well (Zivin, 2017). For example, healthy weight loss and exercise programs have shown to decrease baseline employee healthcare costs in organizations who routinely sponsor wellness campaigns (Zivin, 2017). Conversely, Zivin also indicated that if an organization chooses this route for employee motivation, a focus must be placed on ensuring that several different programs are offered (2017). This is so that the largest number of employees can utilize the beneficial programs; if only one type of program is offered, then only a select group of employees will utilize the service and therefore only that group would be motivated by the program (Zivin, 2017). Von Bonsdorff (2011) indicates that more modern motivational theories, such as wellness campaigns and healthy behavior rewards, apply more to a more modern workforce. Older individuals in the same workforce may respond more positively to traditional motivational campaigns such as bonus structures and paid time off (Von Bonsdorff,
2011). With these differing responses from different age groups, it is imperative that the leaders in those department find a collaborative way to motivate all of their employees with different types of programs.
According to Beyazin (2017), studies in the realm of employee motivation have oftentimes focused solely on a single profession within the healthcare industry (i.e. pharmacists,
33 nurses, or physicians). A gap was identified in that, while there is a plethora of studies available on employee motivation and job satisfaction in healthcare, less of them are aimed at the organization or facility level and are instead focused on the position-level within the industry
(Beyazin, 2017). According to Sulliman (2009), employee motivation is the determinant as to why an individual chooses one job over another job in the same industry. Therefore, much of the research in the field has focused on that point, and not necessarily the larger organizational level for studies.
In summary, more highly motivated employees will result in a higher success rate for healthcare organizations’ initiatives and quality improvement goals. Leaders must have a strong connection with their employees to ensure that their needs are met, as well as so that the job is completed to the best of the employees’ ability. Intrinsically motivating employees will allow them to feel more connected to the organization and will result in a more committed workforce.
While challenges are inevitable in any large organization, leaders who have developed a highly- motivated team will see their teams persist through those challenges much more quickly and easily than teams that have lower levels of motivation.
Quality Improvement
Improvement within the healthcare field is directly related to the individual professionals working in the field and their ability to carry out quality-improvement methods (Avelar, 2016).
Within the incredibly dynamic and competitive field of healthcare, leaders of organizations should focus on maximizing the human resources of the organization to provide the highest quality of care possible (Shiag, 2016). Shiag indicates that motivated employees complete their job duties more efficiently, and help the organization grow at the same (2016). In order for hospital and healthcare organizations to gain a competitive advantage in the realms of quality 34 and reputation in the industry, they must retain their quality employees and keep them motivated
(Shiag, 2016). Historically, financial compensation has been seen as a primary motivator in the field; however, in more modern workforces and organizations, money alone cannot guarantee a motivated workforce (Shiag, 2016). Therefore, additional motivational techniques must be implemented in order to retain quality employees, increase productivity, and ensure consistent growth in quality in the industry.
According to Cadwallader (2009) a major quality improvement trend in healthcare is customer-service focused initiatives. These initiatives are carried out through the usage of high levels of training for employees to create a more patient-centered group of services within the organization (Cadwallader, 2009). A motivated and committed workforce is a key component of an organization’s success in implementing and executing new quality improvement initiatives focused on customer service and patient centeredness (Cadwallader, 2009). Shiag (2016) also discussed the importance of retaining motivated employees in order to drive organizational plans and initiatives forward consistently. Leaders have a responsibility to carry out new quality improvement initiatives within the organization and retaining and motivating quality employees ensures that those plans for implementation continue to progress appropriately which benefits not only the organization, but also the patients being served as well (Cadwallader, 2009).
Quality improvement is a concept that is equally important from the leadership perspective and from the frontline employee perspective. According to Anderson (2008), there is a strong correlation between transformational leadership theories and the understanding of quality improvement throughout an organization. In order for quality improvement initiatives to be successful, those initiatives must be fully understood at every level of an organization. With the need for understanding, traditional leadership theories, such as more controlling theories,
35 may not provide enough communication between leaders and followers to develop an understanding of the initiatives. Anderson (2008) discussed that organizations with a high number of transformational leaders throughout the organization have much higher levels of understanding throughout all levels of employees in that same organization. One method of communication pertaining to quality initiatives, status of current initiatives, and changes in quality measures are balanced scorecards (Gunawardena, 2011). These scorecards allow both leaders and followers to focus on the initiatives that are the most important (Gunawardena,
2011). Transformational leaders are able to have much more interaction-time with their followers; therefore, those followers will have a higher level of motivation from that leader as well as a higher level of understanding of that leader’s initiatives and goals (Anderson, 2008).
Hinchcliff (2013) also indicated that collaborative types of leadership, such as transformational theories, are critical enablers of quality improvement initiatives. The higher level of understanding in the frontline employee section of an organization will allow quality improvement initiatives to be set up for a greater degree of success.
Low Employee Motivation and Productivity
When employee motivation and morale levels are low, or lower than normal, this scenario can affect many different aspects of operations within healthcare. Most notably, low employee motivation and morale can result in a staff or team that has a much lower level of productivity than that of a more highly-motivated staff or team. Productivity is ever-important in the healthcare industry due to the need for employees to be proactive in their respective roles, and the need for quick action to be taken. This is because if action items are postponed, due to the nature of the field, individual patients’ lives and livelihoods could be at risk. Modern workplaces are constantly evolving, and employees are now required to take more proactive 36 approaches to tasks that are outside of their job descriptions (Parker & Wang, 2015). Levels of motivation in a given staff can have a large direct impact on the levels of productivity in the staff.
According to a study by Kleinbeck (2000), employees who showed low levels of motivation in a team setting showed a markedly lower level of productivity. The study was conducted in the manufacturing industry; therefore, outputs were more easily measured than a more complex role in healthcare. The particular study focused on psychological team-based relationships. Teams who operated more cohesively, inclusive of their leader or manager, showed the higher levels of manufactured items at the end of the testing phase (Kleinbeck,
2000). Within healthcare, while “outputs” may not be as easily measured, team cohesiveness and leader-follower relationships carry equally important weights in the field. If a leader does not foster a strong communication channel both between team members, and between those members and the leader individually, then productivity and morale will suffer when compared to a team in healthcare that does have clear and open communication.
Poor Leadership and Low Morale
The relationships between leaders and followers can also have an incredibly beneficial, or an incredibly detrimental, effect on employee motivation and morale. Due to the nature of the healthcare field, especially in the senior healthcare industry serving elderly patients, it is important for employees at all levels of an organization to be focused and motivated. As discussed earlier, lack of motivation can result in less productivity and proactivity in employees’ individual roles. Leaders have to be equally as focused on the relationships that are developed with followers.
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According to Kleinbeck (2000), as processes and roles of frontline employees become more and more complex as the industry evolves, leaders often find it difficult to gain the technical knowledge of each and every role that they are responsible for managing. Additionally, when leaders place higher levels of pressure on their followers (i.e. goals to achieve, increased workloads), without proper knowledge of employees’ individual job responsibilities or current workloads, it can result in those employees becoming psychologically withdrawn from their respective work (Kleinbeck, 2000). These one-on-one relationships can have a “snowball” effect if multiple employees in a department are affected, and if multiple departments in an organization are effective. If leaders do not have strong connections with their employees, it can have detrimental effects on the productivity from a small departmental scale all the way to a large organizational scale.
Mitigating Factors
While there is a plethora of methods that can be implemented within an organization in order to mitigate low motivation levels, the methods discussed here have been found to be successful in the healthcare and the business fields. A motivated employee oftentimes can be analyzed through the Maslow Scale. In order for an employee to complete an action without being specifically instructed to do so, that employee must have some level of motivation. When an employee is rewarded for performing a specific behavior with a reward of value, that behavior becomes more attractive to complete (Becchetti, Castriota, Tortia, 2013). These items can be seen as external motivators. In addition to those external motivators, employees can also be intrinsically motivated.
Intrinsic motivation is generally seen within higher-level positions. In the scenario of the senior living industry, examples could include nursing supervisors, shift supervisors, and senior 38 frontline staff. Leaders may need to look at those positions, and target their motivation, differently than a frontline employee. If motivated intrinsically, an employee does not necessarily need an external reward as the action itself becomes the reward (Becchetti et al,
2013). An example of developing intrinsic motivation within employees is the opportunity for professional growth (Becchetti et al, 2013). If a specific employee has aspirations to grow within the field through promotions, a leader can pay close attention to those aspirations and present opportunities to gain exposure to new challenges in order to train for future roles. This promise of upward mobility then results in a higher level of intrinsic motivation within that specific employee. With the higher level of intrinsic motivation, the employee becomes more motivated by the tasks at hand, rather than monetary or materialistic rewards for completing those tasks.
According to Bechetti (2013), when employees who are able to be motivated intrinsically, are finally motivated by their jobs or roles, those employees make much more productive employees within the organization. In Bechetti’s study, those particular employees were willing to work longer hours, work on holidays, and take on challenging projects without a great deal of leadership intervention to convince them to do so (2013). Additionally, increased levels of intrinsic motivation can lead to employees who have higher levels of proactivity in their roles, which also is more of a self-driven process than a manager-driven process (Parker et al, 2015).
Leaders who have a stronger connection with their team can more easily implement motivation al methodologies than leaders who experience a disconnect. For example, if a leader were to implement a new process in a department, that new process would be more positively received by employees who strongly connected with that leader as opposed to employees who have never had a strong communication connection with that leader. Therefore, proactive approaches to establish those communication channels will set the leader up for success in future
39 implementations of new processes, as well as set up the team of individuals to successfully adapt to a new process or procedure that needs to be implemented.
Connecting communication and motivation is a manner in which, from the leadership perspective, can be used to increase morale and motivation within a specific team or organization. According to Gupta & Pandey (2015), motivational communication first starts with identifying the needs of the individuals on the actual team. Once these needs are identified, the leader of the team can determine the optimal way to communicate with that by which the team will be most receptive to the communication. This results in removing barriers in communication channels (Gupta et al, 2015). Some examples of this type of communication could be casual approaches to presentations, adding sensitivity into person-to-person communications, and ensuring that conversations are not one-side and the employee has a chance to provide input
(Gupta et al, 2015). These items can be used on an individual basis or when communicating to a team in order for a leader to be best positioned to guide the team in the correct direction.
Motivation and Change
According to Liang et al. (2015), employees’ motivation toward adopting proper usage of a new information system in a healthcare facility is primarily focused around three factors. These factors are the tasks involved in the change, the system itself, and the organizational environment in which the employee works (Liang et al., 2015). Employees can be motivated by goal awareness, or part of the Need for Achievement Theory (Liang et al., 2015). With this type of motivation, employees have a desire to achieve excellence and receive positive feedback from their superior. In an instance of a new information system implementation, these employees would be individuals more willing to learn a new system, and also properly use it in order to receive that positive reciprocated feedback from their manager (Liang et al., 2015). Additionally, 40 according to a study by Liang et al., the concept of goal awareness in employees, particularly in healthcare information technology, when properly managed can result in higher levels of motivation in those particular groups of employees (2015).
According to Brdulak, Senkus, & Senkus (2017), those individuals who are early adopters in the instance of a new information system implementation can be referred to as
“innovators”. Innovators are motivated by the positive feedback from their managers, similar to the goal-aware employees discussed earlier (Brdulak et al., 2017; Liang et al., 2015). While entire teams will not be constructed of innovators, those innovators can lead by example in influencing others on the same team to adopt the proper usage of the new information system or process being implemented. According to Brdlak et al., each person on a tea will bring unique personal expectations, and also unique ways of obtaining feelings of individual belonging
(2017). The innovators and early-adopters on each team are specifically motivated by challenging tasks, and feel rewarded when the challenging task is completed (Brdlak et al.,
2017). Therefore, the challenging task of learning a new system early on, and the feedback from the employee’s supervisor, results in the goal-awareness (Liang et al., 2015) and the motivation through innovation (Brdlak et al., 2017) being satisfied. Similarly, Ghorbani, Pourhosein, &
Ghobadi, 2018 indicated that perceptions of ones’ performance in the workplace can have a strong correlation with their stress level while at work. When these aspects of an employee’s job performance are satisfied or exceeded, these factors are what contribute to a team in healthcare continuing to become more and more highly motivated by a given process or task.
In addition to employee motivation influencing the success of new health information system implementations, big data that healthcare organizations are already using can influence employee engagement and motivation as well. Employee motivation is a factor of workplace
41 measurement that only recently has been researched and recorded in workplaces (James, 2014).
While employee motivation may have been measured on the small scale in the past, the presence of big data, and the systems to manage it within healthcare, now allow organizations to gauge the engagement and motivation levels of their organization on a much broader and comprehensive scale (James, 2014). These measurements at the organization level (through surveys, reviews, etc.) can not only provide feedback to leadership about areas in need of improvement, but it also promotes a message to employees that the organization cares about their input, and that the organization is actually hearing their respective ideas and concerns (James, 2014). This communication of “connection” between employees and the organizational leadership can be motivating to employees in and of itself, in addition to the actual data being collected that can be beneficial to make positive changes in the employee environment within the organization
(James, 2014).
An example of an organization using already-collected data in order to better determine management techniques was found in a study by Rohama, Mardanai-Hamooleh, & Kouhnavard
(2017) which indicated an entire nursing department was facing fatigue due to ethical dilemmas.
The organization was not previously aware of the prevalent issues in the department, and this was due to data collection being completed and then the data analysis portion was not completed afterward (Rhoama et al, 2017). According to James (2014), healthcare organizations oftentimes already have large databases of employee survey data compiled, but the challenge is that hospitals may not have the financial resources to complete all of the necessary analysis to produce an actual output from the data. In addition to hospitals using their own data advantageously for positive changes and growth, multiple health systems can oftentimes utilize their data on common themes (i.e. employee surveys, motivation, etc.) in order to identify
42 geographic trends (Bredfeldt et al., 2013). When these organizations collaborate together with big-data resources, those organizations can find ways to better work together and potentially jointly solve issues that all of the organizations are facing at the same time (Bredfeldt et al.,
2013). Additionally, according to Imani, Salehi, & Hosseini (2012), data already collected by healthcare organizations can be utilized to predict future trends in the workforces, and these trends can be analyzed at either the organizational or at the geographical level.
A potential solution to the nursing department burnout trends identified by Rohama
(2017) was identified by an article written by Ajunwa, Crawford, & Ford (2016) which discussed the usage of big-data information in order to properly develop wellness campaigns in healthcare and corporate organizations to reduce employee burnout. The overwhelming nature of healthcare can often lead to burnout, and Ajunwa et al (2016) indicates that wellness campaigns focused on healthy lifestyles and wellbeing can result in less-stressed workforces as well as higher motivation levels in the departments participating. According to Ajunwa et al (2016), healthcare organizations can potentially use the data already in existence in their databases in order to better develop wellness campaigns that will be positively received by the department or entire organization that will be using the wellness campaign. Additionally, when using such data to develop employee motivation campaigns to rectify issues surrounding lack of motivation or lack of adoption to a new healthcare system, the data must also be highly protected in order to continue to ensure confidentiality to those whose data is in the database.
Systematic Improvements Through Motivation
Working towards a more efficient and effective environment in healthcare while providing high-quality care is a focus that most, if not all, hospitals and health systems have.
While motivation can come in many forms and have many definitions, the term is primarily 43 either internal or external (to the employee), and can be described as a healthcare employee’s willingness to put forth and sustain effort towards a company’s goals (Alhassan et al., 2016).
From a leadership perspective, managing employees to be as engaged and motivated as possible has shown to have a very positive influence on these types of performance improvement initiatives. According to Manley, Martin, Jackson, and Wright (2016), many changes and investments in healthcare fail to provide their full value to the challenges in creating and maintaining a genuinely motivated workforce. Developing new systems that are more patient- focused, and new processes to improve efficiency, are a few areas where systems thinking and the theoretical perspectives combine very well.
According to Reynolds, Sar riot, Swanson, and Rusoja (2018), one of the most applicable aspects of systems thinking in healthcare is teaching and learning. From a leadership perspective, teaching employees the components of new processes can be challenging. When managing through change, leaders can consider employees as separate constructs in the system of the organization (Reynolds, et al., 2018). If more employees are motivated, engaged, and adequately trained on a new internal process or change, the implementation of such change is much more likely to be successful (Manley et al., 2016). Conversely, a lesser-motivated team of individuals may be less likely to buy into a new process or idea in the organization, drastically decreasing the likelihood of success in its implementation. Reynolds et al. (2018) also indicate that systems thinking theories may not be a complete solution to human-related problems in healthcare.
Employee motivation is very psychological and relationship-driven. Reynolds et al. (2018) discuss that humanistic issues in the health field can be overwhelmingly complex, and can have many frailties and complexities that may not be accounted for in a single theory. Therefore, it is suggested that systems theories be used as a lens to look at problems from different viewpoints,
44 and analyze them as constructs and components (Reynolds et al. 2018). Similar to systems theory being used to improve performance in healthcare systems as Chuag and Inder (2009) discuss, these same theoretical constructs can be aligned to improving employee motivation from a systematic perspective as well (Reynolds et al., 2018). Research suggests that leadership attention to, and support of, the psychological needs of healthcare employees creates a more autonomous and self-driven workforce (Williams, Halvari, Niemiec, Sørebø, Olafsen, &
Westbye, 2014).
Another aspect of analyzing healthcare employee motivation from a systems perspective is to consider that motivated employees may not be engaged (or disengaged) by one single factor. According to Hwang, Lee, and Shin (2016), and Krstic, Obradovic, Supic, Stanisavljevic,
& Todorovic, (2019), the end-result of job satisfaction and motivation in an employee’s role may come from several different components working together in that employee’s environment. For example, goal awareness in the organization and self-efficacy in a person’s role both can come into play when determining how motivated and satisfied that employees is in their respective role
(Hwang, Lee, & Shin, 2016). Additionally, Bong (2019) indicates that moral distress in healthcare employees can create lesser-motivated teams and increase employee turnover rates. If leaders are able to analyze an employee’s performance from a systematic point of view, it can allow for a more well-rounded perspective of that employee, and also a better understanding of how to motivate that employee in the healthcare field. A manager or leader can then influence those necessary constructs to build a more highly-motivated employee, and in turn, a more highly motivated team. For example, to understand goal-awareness, McClelland’s Need for
Achievement theory can be applied to a specific situation, which states that employees with high
45 goal-awareness require immediate and concise feedback in order to feel supported and motivated in their work role (Hwang, Lee, & Shin, 2016).
Leaders can utilize a multitude of different perspectives and theories to effectively understand, manage, and develop motivated employees. According to Alhassan et al. (2016), most healthcare employee motivation, from a theoretical perspective, can come from employees attaining their individual needs. Needs vary from employee to employee, and the motivational impacts can vary from employee to employee as well. Alhassan et al. (2016) indicates that employee “needs” can range anywhere from basic psychological fulfilment needs to more complex self-actualization needs on an individual basis. Managing employee behavior in a clinical setting, such as rewarding beneficial behavior, can promote employee motivation from a behavioral theory perspective (Alhassan et al., 2016). From a job-based theory perspective, motivation may be promoted from the design of an individual clinician’s job itself, or the work environment where the job is physically performed (Alhassan et al., 2016). There is also a strong link between an individual’s motivation to perform their job well (whether that is intrinsic or extrinsic motivation), and the quality of care provided and quality of outcomes for the patients being cared for by that specific clinician (Alhassan et al., 2016).
According to Cady, Brodke, and Parker (2019), motivating a team in a clinical setting from a systematic perspective allows leadership to identify which approaches to management may be most influential in building motivation on the team. While goal-setting is an important construct in the “system” of a team, goal-setting alone may not actually result in any motivational improvements (Cady, Brodke, & Parker, 2019). This is because if a team of people have a common goal, but do not necessarily have a requirement to work together (i.e. their jobs are independent of one another), it is difficult to motivate everyone from the same perspective.
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Cady, Brodke, and Parker (2019) further discuss that individuals on a team who are not interdependent on one another may not even be considered a team from a theoretical and systems-thinking point of view. When clinicians on a common team are working in roles closely related to others, all of those different employees and different jobs become more committed to a shared goal. In this type of team scenario, according to Cady, Brodke, and Parker (2019), leaders can more easily motivate a group of people to engage in a new process, improve performance, or become more productive as a whole. Therefore, it is important for those in leadership positions to understand not only individual employee dynamics, but also the presence (or lack of) formal and informal teams within the organization as well.
Employee motivation in healthcare facilities, when analyzed from a systematic framework and perspective, is influenced by a multitude of variables within the given system or environment. While motivational priorities of employees, such as intrinsic or extrinsic motivation, takes a large role in building more motivated teams, the style of leadership that a manager utilizes or possesses can have an impact on motivation as well. A leader must be able to understand how employees on the team are motivated as individuals, and must also understand how their own leadership style can impact the successes or failures in increasing motivation within a team. Just as there are a multitude of theories applicable to frontline employee motivation, there are also a multitude of theoretical constructs surrounding leadership and management styles in the workplace. A leadership theory that relates closely with systematically increasing employee motivation is transformational leadership. Transformational leadership, according to Jooste, Kodisang, and Magobe (2014) involves creating motivational practices that support positive behavior guided by a shared value or shared values for the team. This leadership style is put into practice by encouraging responsible decision-making on the job, and exercising
47 good judgement when mitigating a problem or challenge in the employee’s environment (Jooste,
Kodisang, & Magobe, 2014). The transformational leadership style, when implemented in clinical settings, paves the way to help employees realize their highest capabilities through fostering vision-building and support for each and every employee by the leader of that team
(Jooste, Kodisang, & Magobe, 2014). Similarly, according to Krstic et al. (2019), developing vision-driven and motivated teams in clinical settings is a tactic to mitigate employees’ resistance to changes such as new processes and system implementations. Leaders who are effectively able to leverage a beneficial leadership style combined with an understanding of individual employees’ motivational needs can successfully develop a more creative, cohesive, and motivated team that is more likely to adapt to new systematic changes in a positive manner
(Krstic et al., 2019).
Health Policy Impacts on Rural Healthcare
As discussed by Pierce (2007), it is equally important and urgent that a deeper understanding of healthcare disparities in rural areas is developed by both the policymaking perspective as well as the healthcare service delivery perspective. According to Zhang, Tao, and
Anderson (2003), rural residents between the ages 18 and 24 frequently have the worst availability of healthcare in their geography. Rural residents, due to geographical disparities such as distance to the nearest healthcare facility or the general availability of such facilities are much more likely to postpone seeking care due to those barriers (Zhang, Tao, & Anderson, 2003).
These challenges along with a clear understanding of who lives in the rural areas, where the residents work, and their specific needs as patients are fundamental in building constructive policy discussions focused around rural healthcare needs, and the resulting potential policy changes (Basanta, 2002). 48
Similarly, Simmons, Huddleston, Morgan, and Feldman (2012) and Dougherty and
Simpson (2006) discussed that health policy developments at the national level may not always fully take into account the specific needs of rural patient populations. Rural geographies, as discussed, face very unique disparities in available of care and distance to healthcare facilities.
Therefore, policies that are developed at any level must include enough data and support in order to factor in the needs of rural geographies and urban geographies equally (Simmons et al., 2012).
The researchers indicated that policy-level decisions at the state or federal level are oftentimes made on a very broad basis, meaning that new policies implemented in that way may disproportionately benefit urban residents over rural residents (Dougherty & Simpson, 2006).
According to researchers, past policymaking procedures focused solely on rural geographies have primarily targeted bringing more healthcare providers to rural areas or areas that have a lack of access to care (Simmons et al, 2012; Dougherty & Simpson, 2006). However, because these efforts have not always been successful, or have only been partially successful, the usage of telemedicine is proposed as a solution to increase access to primary and specialty care to rural geographies in the US. According to Batis et al. (2017), telemedicine is an example of healthcare organizations becoming more innovative in the provision of care to underserved areas. Leaders of rural health systems who support innovative technologies such as telemedicine allow for those rural communities to receive cost-effective and timely care while efficiently utilizing valuable clinician resources (Batis et al., 2017). An example of the lack of success in past policies is a case study from North Carolina which indicated that 25% of all rural healthcare facilities developed or opened in a twenty-year timeframe ended up closing without any viable replacement of services (Wright, 2009). An additional policy factor contributing to access inequities is that policies focused on incentivizing physicians to provide care to rural patients
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(enacted in the 1908’s) were not sustained from a funding standpoint, and therefore were not useful long-term (Cowper & Kushman, 1987). With these many past policy developments that were not successful, it has proven that a more modernized and well-rounded approach should be taken to future policy developments supporting rural healthcare advancement.
In past research, focused on the important components of health policy in order for it to truly be successful, Russell et al. (2013) indicated that two main components should be focused upon in new policymaking in order to ensure equity. One component is timeliness includes having care available close to home so that residents can seek care immediately when needed, and a second component is acceptability which focuses on the fact that the care that is available needs to be quality care that can truly address the needs at hand (Russell et al., 2013). With the issues in policymaking present such as inequities between urban and rural geographies from the same policies being applied, discussed by Simmons et al., (2012) and Dougherty and Simpson
(2006), utilizing the methodology employed by Russel et al. (2013) could prove to be an effective starting point for policymakers to ensure that future developments take into account the unique needs of both types of geographies.
Literature Review Summary
In conclusion, the primary topic of the dissertation research will be employee motivation in healthcare and the psychological relationships between leaders and followers. There are a multitude of leadership theories, such as transactional, servant, and transformational leadership that are prevalent in healthcare today. Some leadership styles are more effective on different age groups, which is an important aspect for leaders to keep in mind as they manage through change in organizations. More highly motivated workforces can produce a much more effective and efficient healthcare system overall. More importantly, quality improvement methods are 50 advanced and implemented much more successfully when they are introduced to workforces that are more highly motivated to accept change. It is crucial for leaders to be aware of, and competent in the understanding of, employee motivation and its’ many benefits to healthcare organizations and the industry as a whole. After an exhaustive literature review into leadership and employee motivation alongside the challenges in rural healthcare, the review failed to reveal any similar research studies that have been conducted in the past. Because of this lack of current research, the proposed research study is targeted at filling a gap in research by conducting a novel case study using the methods detailed in Chapter 3.
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CHAPTER III
METHODOLOGY
Qualitative Design
This chapter will review the design of the research study, the rationale for the chosen methods, the role the researcher played, how the data were collected, and how the data were analyzed. The research method that guided this study was a qualitative case study design. In general, qualitative research aims to interpret social phenomena such as interactions, motivation, behavior, and communications, in terms of the meanings that people associate with those phenomena (Neutens & Rubinson, 2013; Pope, 2020). These types of studies focus on speech, actions, behaviors, and texts as opposed to more numerical and statistical comparisons present in quantitative research (Pope, 2020). Qualitative research incorporates the inclusion of both qualitative data collection, and qualitative methods of analyzing the data that is collected. The data collected in qualitative research is comprised of words, visual cues, and descriptive forms of data (Pope, 2020). The analysis of that data involves the utilization of text-based, interpretative analytical methods (Pope, 2020). Inductive reasoning is used to analyze qualitative data meaning that data is collected first, and is then analyzed for grouping, trends analysis, and comparisons at the conclusion of the study (Neutens & Rubinson, 2013). In a simple comparison discussed by
Pope (2020), quantitative research may aim to answer questions such as how many of a given item are present in an environment; on the other hand, qualitative research may aim to answer questions such as what are peoples’ perceptions of X, or why do peoples’ perceptions of a given figure vary in different scenarios (2020). Qualitative research is used in studies aimed at understanding how things work, or what things mean to the participants, and data are collected at the location where the research or case study is being conducted (Neutens & Rubinson, 2013). 52
There are many strengths associated with employing a qualitative research methodology in a healthcare environment. According to Neutens & Rubinson (2013) and Pope (2020), a major strength of qualitative research in healthcare is that this type of methodology is well-suited for studying people, their actions, and their perceptions in true, real-world environments instead of experimental environments. There is an aspect of “naturalism” included in qualitative methods, which Pope describes as depending on interacting with participants in their own territory, using their own language, and doing so on their own terms (2020). Researchers can interact with participants in many different ways in qualitative studies, such as observation, interviews, focus groups, documentary analysis, and examining historical documents (Neutens & Rubinson, 2013;
Pope, 2020). In most cases of qualitative research, the researcher as an individual is the primary person collecting the data from all participants (Neutens & Rubinson, 2013).
Qualitative research is increasingly being utilized in healthcare, as organizations continue to become more complex, in order to inform and evaluate policymaking, organizational reform, and changes in the provision of clinical healthcare services within those organizations (Pope,
2020). In addition to those organizational complexities, qualitative methodologies are able to study employees and human behavior in appropriate detail to collect useful data and insights from the participant populations according to Pope (2020) and Enninful, Boakye, and Osei
(2015). Most commonly, human behavior such as employee motivation and leadership styles can be studied by gathering qualitative data through in-depth interviews, observations, and other descriptive tools depending on the environment and the desired outcome (Neutens & Rubinson,
2013). Because researchers attempt to gather very detailed, comprehensive, data sets in qualitative research, researchers oftentimes transcribe quotations from the participants, take notes of the surroundings, document the environment around the study, and ensure that all possible
53 details are recorded in order to appropriately draw conclusions and analyze trends from the data set (Neutens & Rubinson, 2013). The participant perspective, or how people live their lives and make sense of their worlds, is of the utmost importance in qualitative data collection. This is because qualitative data analysis does not concentrate on lists or frequency counts as quantitative research does; instead, qualitative research identifies meaning, how things work, and the impacts of certain behaviors in a given environment (Neutens & Rubinson, 21013).
Rationale for the Design
The design that was employed in this research study included a tool to conduct interviews with participants, and qualitative data analysis methods once the dataset was collected by the researcher. Utilizing a qualitative case study design, and employing a semi-structured interview protocol, allowed the researcher to gather data that is in-depth, comprehensive, and clear.
According to Shi (2008), qualitative research allows researchers to perform exploratory discovery, and to build toward trends and patterns within the study group. Qualitative research involves collecting detailed data around a phenomenon, in this case employee motivation and leadership styles, which is sometimes unattainable with a more rigid quantitative design.
Qualitative investigators and researchers analyze the character or nature of something, not necessarily the quantity of something (Roberts, 2010). According to Shi (2008), when data needs to be collected on topics of attitudes, feelings, motivation, and behavior, a qualitative approach is more appropriate than a quantitative approach due to providing a foundation for the researcher to understand the dynamic and complex processes involved. Roberts (2010) also discuss that qualitative approaches are more appropriate in case studies where intricate details of phenomena need to be conducted. According to Neutens & Rubinson (2013), qualitative approaches to research and data collection are most capable of capturing the data necessary to understand 54 specific human behaviors, motivations, and interactions within an environment. Given the complex healthcare environment where the research will be conducted, and the human behaviors of motivation and leadership constituting the focus of the study, a qualitative design was most appropriate in this case in order to most accurately gather the data, and analyze that data for useful trends and commonalities.
Type of Design
With the purpose of this research being to understand and analyze the phenomenon of employee motivation and leadership behaviors in rural outpatient healthcare, a descriptive case study design within the qualitative methodology was most appropriate. A descriptive design aims to gain an understanding of particular groups and phenomena as completely, precisely, and accurately as possible (Shi, 2008). Under a qualitative approach, words, trends, details, and perspectives are gathered from the participants, as opposed to numbers within a quantitative design (Roberts, 2010). Due to the flexibility afforded under a qualitative design, as well as the comprehensive data collection capability of a qualitative interview process, a qualitative design was most appropriate to answer the questions in this study pertaining to employee motivation and leadership behaviors within a rural outpatient healthcare. According to FitzPatrick (2009), qualitative approaches to data collection allow the researcher to gather a data set comprised of
“rich data”, meaning that it accounts for many points of view, and as much detail as possible on a given behavior or human interaction.
Researcher’s Role in the Methodology
Because this research project is implementing a qualitative approach, the researcher served as the investigator, and the participants’ identities were technically known to the
55 investigator (Shi, 2008). Each of the semi-structured interviews were conducted solely by the researcher, and were individual interviews with each participant separately. According to
Neutens & Rubinson (2013), the researcher generally the person also gathering the data and conducting interviews when a qualitative approach is implemented.
The researcher was responsible for submitting documentation of the research prospectus and appendices under both the Franklin University Institutional Review Board (IRB), as well as the Institutional Review Board of the organization where the research was conducted and the participants were recruited from. The organization’s IRB process was completed first, then the
University’s IRB process second. Standard requirements of the organization for recruitment and consent documents were similar to the required documents that were submitted to the university’s IRB. It was the responsibility of the researcher to ensure that both IRB approvals are completed, and approval letters were received, prior to initiating the data collection process.
The researcher worked with the research department within the comprehensive health system that is responsible for oversight of all clinical and non-clinical research, as well as the
Institutional Review Board process. In communication with the research department, the researcher developed the interview protocol, consent documentation, sample selection process, and recruiting documentation to be compliant with the research department’s compliance requirements. The Subject Matter Experts (SMEs) who participated in the data collection tool validation process were also part of the comprehensive health system, and provided signed letters of support after the validation process was complete. The detailed process is discussed later in this chapter.
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Site and Sample Selections
The site where this research was conducted was within a comprehensive health system in the South-Central portion of Pennsylvania. This health system had an expansive outpatient footprint, and provides care to primarily rural geographies. The outpatient service line allowed for access to a large group of participants in leadership roles whom hold similar roles and perform similar functions. According to a personal interview with a health system administrator, the population from which participants were able to be recruited is 90 individuals, all of whom oversee similar groups of frontline staff, but their oversight did not overlap with other leaders in the organization (Administrator, 2020, January).
Small, convenience sampling was employed due to the access available to the study population, and to the inclusion criteria which required participants to hold a specific title
(Roberts, 2010). Participants that were recruited as part of the population of 90 referenced previously had the title of Practice Manager or Senior Practice Manager. These roles manage teams ranging from ten to thirty staff members (Administrator, 2020). These roles ensured that the analysis between leaders, and the functions they served, and the staff that they managed, were consistent. While there was a vast number of leaders within the health system, this type of grouping allowed for managers of similar levels, functionality, and service line to be recruited to participate in the study. Each individual in the identified sample group of 90 had equal opportunity to participate, and were recruited identically to the others in the group. Out of these
90 potential participants, the goal was to interview 25-35% of the group (23-32 subjects in total).
After the research was completed 40 participants agreed to be interviewed. These potential subjects were not in positions that report to the researcher, to avoid any perceived coercion to participate in the study. Reference Appendix B for the recruitment communications, employing
57 electronic mail communication, which provide participants with the opportunity to participate in the study.
Subjects from the sample population were recruited through a number of different communications. Primarily, communications aimed at recruiting participants were sent via electronic mail internally within the comprehensive health system. An introductory email was sent to all potential participants from a leader of the organization, providing an overview of the study, introducing the researcher, and describing the benefit of the research. A secondary email was sent to the same group of potential participants from the researcher, again describing the study and inviting the participants to coordinate a time to participate in the research. Participants were invited to participate in the semi-structured interview over the phone, or via videoconference, depending on their preference and comfort level. These recruitment communications were part of the research protocol submitted to the health system’s IRB for approval and compliance as well. Please reference Appendix B for the detailed communications to be utilized in recruitment of study participants.
Data Collection Techniques
The qualitative data in this research study were collected through the utilization of a semi-structured interview protocol. Reference Appendix A for the implemented interview protocol. The semi-structured interview contained a core of structured questions from which the interviewer was able to move in related directions for in-depth probing (Neutens & Rubinson,
2013). This implementation of semi-structured interviews was appropriate in the case of this research due to the need to gather in-depth data from each participant, and the semi-structured approach allowed the researcher to ask probing questions if a particular answer from a participant was vague, or of more details were needed to completely answer the questions. 58
Interviews were conducted virtually through electronic videoconference or teleconference communications between the researcher and the participant. Each interview started with reviewing the informed consent documents, and informing the participants about the study itself, and gaining consent prior to starting the list of interview questions (See Appendix C for these informed consent forms). Consent was required in all modalities (phone and videoconference) of communication to complete the interviews. The interview was divided into two separate sections, one focused on how the leader manages and leads their respective staff, and the second focusing on how well their respective employees are motivated, and what techniques between the leader and follower are most effective in motivating those employees. The leadership section asked questions from a variety of viewpoints and directions. The participants were asked about their leadership from their own perspective, from the perspective of their leader, and from the perspective of the staff that they manage. The motivation section asked questions about specific successes and challenges the leader has faced in motivating their staff, and asked for examples to ensure hones and clear answers are being provided. Probing questions were included in both questions in order to prompt the researcher to look for clarity in specific areas of each question from each of the participants (Roberts, 2010). At the conclusion of the interview, as suggested by
FitzPatrick (2009), participants were debriefed on the researcher’s notes, and were given the opportunity to add any details that may have been missed either in the questioning process or in the transcription process of the researcher. FitzPatrick indicated that this debriefing method ensures that as many details as possible are gathered from each and every interview, thus contributing to a much more accurate representation of the study population at the conclusion of the study (2009).
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A summary of the interview protocol questions, as well as the research question discussed earlier are summarized below in Table 1. Please reference Appendix A to review the full interview protocol to be utilized in the research.
Table 1. Summary of Interview Protocol Questions Research Question: “What leadership behaviors and leadership styles are most effective in developing a motivated frontline team in an outpatient care service line within a health system serving a rural geography in South-Central Pennsylvania?” Semi-Structured Interview Protocol Questions Leadership Style Questions: Employee Motivation Questions:
1. If you were to describe your approach 1. In a general perspective, how to interacting with employees on a motivated would you say your teams daily basis, not necessarily coaching, are? Clarification: they’re willing to but just general interactions, how put in the effort to get the job done, would you describe that approach? get it done correctly the first time, and 2. If you were to describe your approach ensure they are performing the best to interacting with employees when that they possibly can be. coaching for performance 2. If you were to give a general improvement, how would you percentage, what proportion of your describe that interaction? Is it the employees would you say are same for every employee? proactive in their roles, as in they 3. What are three things that, in your independently take steps to avoid an opinion, your employees would issue from happening instead of associate with your leadership style? reacting after it happens? Just three traits, not necessarily an in- 3. What are the top three things, from depth explanation. your individual perspective, that you 4. When delegating tasks to your think contribute most to how employees, what is your go-to process motivated your teams are working in as to how you communicate the rural healthcare? delegation of the work, and also 4. What are the top three things, from ensuring that works gets done your individual perspective, that you properly? think are barriers to your employees 5. How do you generally support becoming more motivated in their employees who are interested in roles within rural healthcare settings? becoming leaders in the future? Have 5. How do you normally reward you successfully coached any employees to recognize positive employees into moving from frontline behavior? (i.e. verbal, incentives,
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to leadership positions while you’ve recognition, group-setting, monetary, been in your role? none, etc.) 6. How would you describe the effectiveness of motivational strategies that have been implemented across the rural health system? 7. How would you describe the effectiveness of motivational strategies that you have personally implemented with your specific team? 8. What other insight or information would you like to share that is relevant to the study but that we may not have discussed during this interview so far?
Research Tool Validation
Determining the validity of the data collection tool, in this case a qualitative interview protocol, is of utmost importance to ensure that accurate, comprehensive, and useful data is collected once the data collection tool is put to use in the research. According to Neutens and
Rubinson (2013), validity is the extent to which a procedure measures what it is intended to measure. In qualitative research, descriptive validity indicates the level to which the proposed data collection tool collects accurate data (Neutens & Rubinson, 2013). In the case of an interview protocol, questions must be phrased to be clear, and in this case with a semi-structured interview, probing questions must also be clear to gather accurate and complete answers during the interview process. Additionally, content validity is a measurement of how well an instrument will produce a reasonable sample of all possible, responses, attitudes, and behaviors (Neutens &
Rubinson, 2013). In order to effectively measure content validity, the researcher who develops the data collection tool cannot be the only individual providing a perspective on the validity of that construct. Therefore, as Shi (2008) suggests, input from professionals who are experts on the 61 topic being studied should weigh in on the validity of the data collection tool as well. Validity is greatly strengthened when all facets of a dimension are taken into account (Shi, 2008).
Validity of the interview protocol in this research was conducted by outside Subject
Matter Experts to ensure that the tool is both construct valid, and content valid. Content validity ensures that the instrument produces a reasonable sample of all possible responses, attitudes, and behavior; and construct validity ensures that the tool permits inferences about underlying traits, attitudes and behaviors accurately (Neutens & Rubinson, 2013). One of the subject matter experts in this case was an individual with expertise in leadership development and the analysis of leadership styles. The second individual was be an expert in human resources to analyze the effectiveness of the interview questions and ensure that the questions were easily understandable to the study population. Reference Appendix D for the subject matter expert letters of support and validation.
To identify the appropriate experts to participate in the research tool validation process, communications were sent to multiple individuals within specialty departments within the comprehensive health system, introducing the study and the researcher, and to learn about the expertise that the individuals could provide. Of the experts who responded and were willing to participate in the validation process, the researcher selected experts from two differing expertise areas—leadership theory and development, and human resources compliance. Appendix D details the communications that were sent to subject matter experts, as well as the letters of support that the subject matter experts provided after the validation process was complete. The process of validating the tool took place with each expert individually. Both started with an initial draft of the interview protocol, from the researcher’s development of the questions based on theory and experience, and meetings were held between the researcher and each expert to
62 deconstruct each question and ensure that each was appropriate to be included, worded appropriately, and was aimed at gathering useful insight from the potential participants. After revisions were made, subject matter experts provided letters of support to indicate the validity of the data collection tool and their support of its usage after IRB approval.
Managing and Recording Data
The interview data set was recorded by the researcher through handwritten notes during the semi-structured interviews. The interview protocol provided space between each question for the researcher to take comprehensive notes during the interview itself. These notes were transcribed into electronic form in a Microsoft Excel database to enable more effective analysis and coding at the conclusion of the data collection timeframe. This database was coded using
ATLAS.ti software to more clearly capture frequencies of discussed themes and specific behaviors during the interviews with all 40 participants. This software utilization is discussed more comprehensively in Chapter 4. The paper records will be maintained by the researcher, and only visible to the researcher, and will be secured in a locking cabinet at all times. Additionally, participant names, departments, demographics, and any other identifying information were not collected from any participants, in order to ensure anonymity of the participants. The electronic format of the data, once transcribed from the handwritten copies, will be maintained on a secure computer by the researcher, and will not be accessible by anyone else. Similar to the paper copies, identifying information and demographic information about each participant is not recorded in order to ensure anonymity of the participants.
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Data Analysis Procedures
Data collected from the qualitative interview protocol needed to be effectively analyzed in order to identify trends and understand the presence of leadership behaviors and motivational phenomena within the study population. Due to the large study population for the conduction of interviews, there was a potential to gather a vast amount of data, furthermore rendering a clear and effective analysis process necessary to understand the data set upon completion of the data collection timeframe. The transcribed notes from each interview were analyzed by identifying themes and patterns, according to Neutens and Rubinson (2013). In order to effectively organize large data set that will result from conduction of the study, notes from each interview were thoroughly re-read, typologies were developed, and a coding process was conducted (Neutens &
Rubinson, 2013). This coding process, organized in the ATLAS.ti software, took place in order to transform the collected data into thorough themes, conclusions, and discussions after the conduction of the data collection process. Additionally, according to Shi (2008), the utilized codes can be developed before the data is collected (precoded), or after the data is collected
(postcoded), or the codes can be altered after data has been collected to better represent the data in need of analysis. Precoding can only be utilized when questions being posed to the participants are closed-ended questions (Shi, 2008). In the instance of this proposed research, the questions will be semi-structured and open-ended, with the potential inclusion of probing questions; therefore, a postcoding process was developed after the data is collected from all participants (Shi, 2008).
During the coding process, two types of codes were utilized for the researcher to analyze each individual interview transcript in the data set. Descriptive codes indicated a class of phenomenon in the transcripts, and explanatory codes indicated where patterns or themes have
64 emerged in the transcripts (Neutens & Rubinson, 2013). After reviewing the transcripts for the open-ended interview questions, a number of explanatory code categories were developed to analyze each question on the interview protocol, and to group the individual codes into themes.
Since all potential answers to the given interview protocol questions are not available until the interviews are conducted, the questions are left as open-ended, and the assignment of coding categories was accordingly completed at the conclusion of the data collection (Shi, 2008).
Summary
The research method that guided this study was a qualitative case study design.
Utilizing a qualitative case study design, and employing a semi-structured interview protocol, allowed the researcher to gather data that is in-depth, comprehensive, and clear.
The site where this research was conducted was within a comprehensive health system in the
South-Central portion of Pennsylvania. The outpatient service line allowed for access to a large group of participants in leadership roles whom hold similar roles and perform similar functions.
The qualitative data in this research study were collected through the utilization of a semi- structured interview protocol. The interview was divided into two separate sections, one focused on how the leader manages and leads their respective staff, and the second focusing on how well their respective employees are motivated, and what techniques between the leader and follower are most effective in motivating those employees. The transcribed database was coded using
ATLAS.ti software to more clearly capture frequencies of discussed themes and specific behaviors during the interviews with all 40 participants. Trends and themes were then identified from the coded data.
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CHAPTER IV
RESULTS AND ANALYSIS
The purpose of this qualitative study was to determine what leadership behaviors and leadership styles are most effective in developing a motivated frontline team in an outpatient care service line within a health system serving a rural geography in South-Central Pennsylvania. The interviews were conducted with leaders who manage outpatient clinical services within a rural healthcare system in South-Central Pennsylvania. This section will discuss the data collected from the study, how the dataset was analyzed, and initial themes that emerged.
Data Analysis
The data analyzed in this section were collected by the researcher by employing the qualitative interview methodology explained in Chapter 3. Recruiting communications were sent to 90 potential participants within the health system who met the study inclusion criteria. As shown in figure 2, 40 participants agreed to participate in the research and completed interviews with the researcher. This results in a study participation rate of 44% being achieved for the research. The goal in the methodology section was to achieve a 25-35% participation rate (23-32 interviews), which was exceeded in this case. Follow-up recruitment communications were not needed as the first round of recruitment communications produced a large enough sample size to fulfill the needs of the study.
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100 Participation Rate 90 80 90 70 60 50 40 30 40 20 10 0 Potential Total Participants Participants (44%)
Figure 2. Participation Rate
Interview Modality
Remote Videoconference 95%
Remote Teleconference 5%
Figure 3. Interview Modality
Participants in the semi-structured interviews were given the option to participate in the study remotely through either remote teleconference or remote videoconference modalities. Both options were made available to make it possible for subjects to participate in the most convenient way for them. The interview modality was originally planned to be comprised of face-to-face interactions; however, as discussed in Chapter 3, adjustments were made due to the COVID19 pandemic to adhere to safety protocols implemented by both the both of the governing IRBs for
67 this study. As depicted in Figure 3, 95% of the participant group (38 participants) engaged in the study via remote videoconference, and 5% of the participant group (2 participants) engaged in the study via remote teleconference.
Participant Education Level
Master's Degree 15%
Bachelor's Degree 55%
Associate's Degree 13%
No College 18%
Figure 4. Participation Education Level
A small amount of demographic data was collected from each interview participant in questions one and two, which were focused on tenure in leadership and education levels respectively. Given that a thorough literature review failed to reveal any similar study, a demographic component was added to the study on this unique population. More detailed demographic information was not collected because the interviews were to be confidential and anonymous in nature as discussed in the methodology chapter, and also because it may not have added value to answering the research question more thoroughly. The tenure of the participants in their leadership positions ranged between 1 and 22 years, with an average of 8.5 years for the participant population. As depicted in Figure 4, 18% of the group (7 participants) had no college education. 13% of the group (5 participants) had an Associate’s degree. 55% of the group (22 participants) had a Bachelor’s degree. And 15% of the group (6 participants) had a Master’s degree. According to the US Bureau of Labor Statistics, the typical minimum education for employees in management roles within healthcare is a Bachelor’s degree or higher (2020). 68
Manager Staff Interaction Approaches
Staff Inclusion 16
Non-Personal Interactions 4
Personal Interactions 62 Frequency
Figure 5. Manager-Staff Interaction Approaches
When participants were asked about their approach to daily interactions with the teams that report to them, three major themes emerged. Primarily, participants mentioned personal interactions between the manager and staff, non-personal interactions between the manager and staff, and staff inclusion, depicted above in Figure 5. Participants mentioned employing personal interactions fifteen times more than they mentioned employing non-personal interactions. The personal approaches most frequently mentioned were having informal conversations daily (17 mentions), engaging in morning rounding with staff (15 mentions), having an open-door policy
(12 mentions), and checking in on staff multiple times throughout the day (11 mentions). The lesser popular non-personal theme included mentions of sending daily staff emails (11 mentions) most frequently within that theme. Staff inclusion in everyday affairs was also mentioned 16 times by the participant group. Within the staff inclusion theme, Participant 5 stated “I interact with my staff every day as if I am another team member”, and Participant 21 stated “I ask for my team’s input, even on small things, to keep them engaged”.
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Performance Improvement Conversation Delivery Secondperson 8 Proactive 5 Positive 16 Nonconfrontational 3 Expectations 8 Direct 10 Conversational 21 Confident 1 Frequency
Figure 6. Performance Improvement Conversation Delivery
Performance Improvement Conversation Customization
Custom approach for every employee 29%
Same approach for every employee 71%
Figure 7. Performance Improvement Conversation Customization
While the question about approaches to daily staff interaction was a relatively broad question for participants, a more specific question was next asked which inquired about the participants’ approaches to conducting performance improvement conversations with their staff.
Five participants mentioned that they strongly disliked having these types of conversations with staff, while only one participant out of the group mentioned enjoying these types of conversations. Six participants mentioned that they customize their coaching conversations to 70 each individual employee, based on which methods best resonate with the employee, and fifteen participants mentioned that they do not customize their coaching conversations, as it makes the process easier for them as a manager (summarized in Figure 7 above). As depicted in Figure 6,
21 of the participants mentioned that they attempt to make these sometimes-uncomfortable conversations as conversational and informal as possible with the employee, in an effort to make them less intimidating. Sixteen participants mentioned that they always keep these conversations positive, and not punitive, in nature. Five participants mentioned being proactive in their performance improvement conversations, by having smaller, in-the-moment conversations about performance issues instead of waiting to have a formal sit-down conversation about an issue.
Table 2. Leadership Descriptors Leaders asked to provide 3 words that their staff would use to describe them. Descriptor Frequency Mentioned Approachable 16 Fair 15 Dedicated 12 Supportive 12 Compassionate 10 Honest 10 Assertive 6 Collaborative 6 Fun 5 Flexible 4 Appreciative 3 Meticulous 3 Transparent 3 Trustworthy 3 Innovative 2 Kind 2 Mentor 2 Proactive 2 Understanding 2 Calm 1 Timely 1
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To get a different perspective on each participant’s leadership, participants were asked what three words their staff would use to describe them as a leader. This produced 120 answers, three for each of the 40 participants, and only 21 different descriptors. This shows that there were many similarities between the participants in the perspectives that they provided for this question. As shown above in Table 2, the most frequently mentioned descriptors were being approachable, fair, dedicated, and supportive. The most infrequently mentioned descriptors were being proactive, understanding, calm, and timely. This question proved to be a challenging question for participants, with many mentioning something similar to a quote from Participant 12 who stated “it is difficult to boil this down to only three words that my staff would use to describe me”. When developing the interview protocol questions with the subject matter experts, these questions asking for different perspectives were intentionally added in order to understand participants’ leadership styles from more than one point of view. This question prompted each participant to think about their leadership from their staff’s perspective, instead of from their own perspective.
Next, participants were asked about their engagement in delegation with their staff, and methods in which they use to delegate projects and tasks to their teams. Thirteen participants mentioned that they dislike delegating tasks, while only one participant mentioned that they enjoy delegating tasks to their team. Participant 31 indicated that they strongly dislike delegation and stated “I can do it faster than my staff, and it’s easier to just do it myself”. The control over which participants retain over delegated projects was split almost half-and-half amongst the participants. Nineteen participants mentioned that they empower their employees to own the delegated projects and trust them to get the work done, whereas 20 participants mentioned that they retain control of the delegated project and micromanage each step of it along the way.
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Eighteen participants mentioned that they only follow up on a delegated task informally, while sixteen participants mentioned that they follow up on delegated tasks formally with strict deadlines and meetings that are scheduled in advance. When communicating the delegation of a task, ten participants mentioned that they use impersonal communication methods such as email or text messages, while 23 participants mentioned that they use personal communication methods such as informal meetings, scheduled meetings, or talking one-on-one with their staff.
Nine participants discussed that they ask for volunteers from their team as a whole when determining who to delegate a task to, and nineteen participants mentioned that they usually have a specific employee in mind when they need to delegate a task, and that they only communicate the delegation to that single employee.
Approaches to Developing Employees Mentioned 120 97 100
80
60 54
40
20
0 Passive Active Approach Approach
Figure 8. Approaches to Developing Employees
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Leaders' Connectivity With Their Direct Managers
Feel Disconnected 37%
Feel Connected 63%
Figure 9. Leaders’ Connectivity with their Direct Managers
When participants were asked about the approaches they employ to develop the employees that work under them, two major themes emerged. All of the response to this interview question fit into themes of either taking active approaches to developing their employees, or taking passive approaches to developing their employees. Active approaches to development were mentioned 97 times in the responses, and passive approaches were mentioned
54 times in the responses, which are depicted above in Figure 8. Some participants mentioned both active and passive approaches together in their answers to this question. Some of the active development approaches that were mentioned were assigning challenging tasks to employees who are interested in growing (12 mentions), adjusting work schedules to accommodate employees going back to school (11 mentions), identifying informal leaders on their team who have growth potential (15 mentions), involving staff in leadership decision-making (10 mentions), and knowing their employees personal and professional aspirations (19 mentions).
When discussing identifying informal leaders, Participant 9 stated “sometimes staff may not know of their abilities to do more than just their current job, and it is my obligation to open them 74 up to new challenges”. Some of the passive development approaches that were mentioned were recommending external education (17 mentions), referring the employee to another department for advice (11 mentions), referring the employee to human resources (14 mentions), and waiting for the employees to approach them to express interest in growth (7 mentions). As a whole, the participant group mentioned 79% more active approaches than passive approaches in regards to growing their employees.
Participants were asked about advice that they have received from their direct manager regarding their leadership in their current role. Two main themes emerged in the responses from this question, which are summarized in Figure 9 above. 37% of participants indicated that they feel disconnected from their direct manager, and 63% of the participants indicated that they feel connected to their direct manager. Within the 37% who felt disconnected from their manager, 8 participants indicated that their manager frequently changes, so they have no connection to them, and 17 participants indicated that they do not receive any coaching or feedback from their direct manager. Within the 63% who felt connected to their direct manager, 9 participants indicated that their manager had given them advice on career growth in the past, 18 participants indicated that their manager had given them feedback on personal growth or honing of personal leadership skills, and 16 participants stated that their manager only provided them with feedback on specific questions about work-related tasks.
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Table 3. Components of Effective Leadership Leaders asked to describe the single most important component of effective leadership. Descriptor Frequency Mentioned Clear Communication 12 Authenticity 9 Lead by example 6 Know staff personally 5 Availability 4 Trusting 4 Flexibility 2
In the last question of the leadership style section of the interview, participants were asked in a conclusory question to pinpoint the single most important component of being an effective leader from their perspective. Out of the 40 participants, only seven different descriptors were mentioned in all of the responses, which are summarized above in Table 3. The most frequently mentioned component was clear communication with staff (12 mentions), followed by displaying authenticity (9 mentions), and leading by example (6 mentions) to as the top three components mentioned from the participants during the interviews.
Current State of Leaders' Individual Teams Motivation
Mixed 35%
Positive 58%
Negative 7%
Figure 10. Current State of Teams’ Motivation
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To start off the employee motivation section of the interview, the first question asked to participants was a broad question inquiring about the current overall state of each participant’s team. Three major themes emerged from this question, primarily grouping the responses into categories of positive, negative, and mixed results. Out of the 40 participants, 58% mentioned the current state of their team’s motivation in a positive manner, 35% mentioned that their teams are comprised of a mixture of motivated and unmotivated staff members, and 7% mentioned that the current state of their team’s motivation in a negative manner. Within the mixed category,
Participant 37 stated “I have some staff who are extremely motivated, and some who are very unmotivated. Some have high career aspirations, and some simply want to do their job for the paycheck”. Additionally, Participant 6 stated “My team sticks together well. But they have some days where the team is very well motivated, and some days where they just are not engaged at all”. Participants were next asked to give a proportion of their team that they thought was made up of the most highly motivated employees. The average across all 40 participants was a proportion of 54% of their teams being as highly motivated as they possibly could be. Within the group of responses, the highest mentioned proportion was 100%, and the minimum mentioned proportion was 20%.
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Top Drivers of Motivation (Categories)
Organizational Aspects 12%
Personal/Managerial Aspects 88%
Figure 11. Top Drivers of Motivation (Categories)
Top Drivers of Motivation (Frequency)
Personal Work Environment 20 Personal Team Dynamics 26 Personal Provider Feedback 7 Personal Patients 17 Personal Manager Recognition 15 Personal Inclusion 18 Organizational Growth Opport. 2 Organizational Compensation 4 Organizational Committees 1 Organizational Pride 7
Figure 12. Top Drivers of Motivation (Frequency)
Next, participants were asked about the top three drivers of employee motivation within the team that they manage. Among the answers provided, two main themes emerged; one theme encompassed personal leader-follower or inter-team relationships, and a second theme encompassed more organization-wide drivers of motivation, both of which are depicted in Figure
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11. All of the response either fit into the category of personal relationship aspects (88% of the responses), or the category of organizational aspects (22% of the responses). Within the 88% of personal relationship aspects, the drivers of motivation that were mentioned were the work environment (20 mentions), team dynamics (26 mentions), feedback from providers (7 mentions), relationships with patients (17 mentions), recognition from the manager (15 mentions), and staff being included in the manager’s decisions (18 mentions). Within the 22% of organizational aspects, the drivers of motivation that were mentioned were growth opportunities
(2 mentions), compensation (4 mentions), committee involvement (1 mention), and pride in the organization (7 mentions). These drivers are summarized above in Figure 12. Based on the frequencies of top motivational drivers being seven-times more likely to be personal relationship-based in nature, rather than organizational in nature, a clear trend was identified in this question pertaining to the strong impact of the personal aspects of leadership on levels of motivation in employees.
Top Barriers to Motivation (Categories)
Organizational Aspects 54%
Personal/Managerial Aspects 46%
Figure 13. Top Barriers to Motivation (Categories)
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Top Barriers to Motivation (Frequency)
Personal Home Issues 10 Personal Patients 6 Personal Outliers 8 Personal Manager Expectations 7 Personal Involvement 11 Personal Conflict 14 Organizational Growth Opport. 9 Organizational Constant Changes 27 Organizational Compensation 19 Organizational Budget Cuts 10
Figure 14. Top Barriers to Motivation (Frequency)
A contrasting question was then asked of the participants which aimed to determine the top three barriers to employee motivation from each leader’s perspective of managing their own teams. The same two themes that emerged in the motivational drivers question emerged in this motivational barriers question. That theme was that the respondents’ answers could be lumped into categories of either pertaining to personal relationship aspects or relating to organizational aspects of motivation. All of the answers could be grouped into categories of either organizational barriers to motivation (54% of responses) and personal relationship barriers to motivation (46% of responses). Within the 46% of responses that were personal relationship barriers to motivation, the barriers that were discussed were employee personal issues outside of work (10 mentions), the stress of handling difficult patients (6 mentions), outlier employees in the group who weren’t patient-centered or career-driven (such as those who only hold their job for a paycheck, not for career growth) (8 mentions), perceptions of the manager’s expectations
(i.e. perceived fairness) (7 mentions), staff feel like they are not involved in decisions (11 mentions), and interpersonal conflict between employees (14 mentions). Within 54% of 80 responses that were organizational barriers to motivation, the barriers that were discussed were the lack of growth opportunities (9 mentions), constant unexpected policy changes (27 mentions), low compensation (19 mentions), and organizational budget cuts (10 mentions).
These drivers are summarized in Figure 14 above. Based on the percentage of organizational barriers to motivation being 8% higher than personal or managerial barriers to motivation, it is evident that organizational factors are proving to be more detrimental to employee motivation in these outpatient settings than personal barriers to motivation.
Types of Staff Recognition Currently Used (Categories)
Personal/Individual Recognition 49%
Group Recognition 51%
Figure 15. Types of Staff Recognition (Categories)
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Types of Group or Personal Recognition Currently Used (Frequency)
Group Emails 8 Group Events 9 Group Food 14 Group Meetings 18 Personal Cards 11 Personal Customized 8 Personal Individual 11 Personal Meetings 9 Personal Small Gifts 8
Figure 16. Types of Group or Personal Recognition (Frequency)
During the interviews, participants were asked about the methods that they currently employ in the management of their teams in order to recognize accomplishments of employees.
Two primary themes arose out of the data collected from this interview question. Out of the answers provided, the answers primarily fell into two categories consisting of managers giving personal individualized recognition (49% of responses), or managers giving group recognition that may not be personalized (51% of responses). These categories were split almost half-and- half, and are summarized in Figure 15 above. Within those categories, the group recognition types that were mentioned were sending out group appreciation emails (8 mentions), hosting group appreciation events such as team-building exercises (9 mentions), purchasing food items for the team during the work day (14 mentions), and appreciating the team as a whole during staff meetings (18 mentions). The individualized or personalized recognition types that were mentioned were customizing appreciation to each employee (8 mentions), individual appreciation in real-time when a positive action occurs (11 mentions), one-on-one meetings to
82 appreciate staff (9 mentions), and purchasing individualized small gifts to acknowledge actions
(8 mentions).
Effectiveness of Organiation-Wide Motivational Strategies
Mixed Results 8%
Ineffective 63%
Effective 29%
Figure 17. Described Effectiveness of Organizational Motivation Strategies
After asking about the techniques the participants are currently employing to recognize their staff, participants were also asked about the effectiveness of organization-wide recognition campaigns that are planned and executed at a corporate-level, and not at the individual managerial level. The answers to this interview question primarily grouped into three themes consisting of the initiatives being effective, the initiatives being ineffective, or the initiatives having a mixed-result (i.e. motivated some employees, and did not motivate others). 63% of the participants indicated that the organization-wide initiatives had no value and did not contribute to their team’s motivation levels. 8% of the participants indicated that the organization-wide initiatives had mixed results, and motivated some of their employees while not motivating other employees. And 29% of the participants indicated that the organization-wide initiatives had a positive impact on their team’s motivation as a whole.
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Effectiveness of Manager-Developed Motivational Strategies
Effective Ineffective 90% 3% Mixed Results 7%
Figure 18. Effectiveness of Manager-Developed Motivational Strategies
Next, participants were asked a similar effectiveness question, but were instead asked to describe the effectiveness of the motivational strategies that they developed for their individual teams, instead of describing the effectiveness of the organization-wide motivational strategies as the previous question asked. The answers in this question primarily grouped into three categories, similar to the previous question, which were that the strategies were effective, the strategies were ineffective, or the strategies had mixed results. 90% of the participants indicated that the motivational strategies that they developed specific to their team’s needs and interests were effective in motivating their teams. 7% of participants indicated that they had mixed results, meaning that their motivational strategies may have motivated some of their employees, but did not motivate other employees. And 3% of participants indicated that the strategies they planned did not have any impact on their team’s motivation as a whole.
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Additional Insight/Comments at End of Interview
Appreciative of Study 22%
Offered Advice 60%
Nothing Additional 18%
Figure 19. Additional Details and Insight at End of Interviews
The final question of the interviews conducted with each of the participants inquired about any additional insight or information that the participant may have, or anything that they may want to go back and add to any of their answers that they already provided. There were not any participants who expressed a need to go back and add to their previously-answered questions. This was most likely due to the confirmation that the researcher asked each participant after each response. The notes that were taken by the researcher were reviewed with the participant after each question, offering the opportunity to ensure the researcher fully captured what the participant expressed in their response. In the answers that were given to this final question in the interviews, 60% of the participants offered generic advice to the researcher, 22% expressed appreciation for being given the opportunity to engage in the research project, and
18% had no additional comments or feedback to provide to the researcher.
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Analysis Resources
To code the interview data, a structural postcoding method was employed to gather as many themes and insights from the data as possible. Structural coding applies a content-based or conceptual phrase representing a topic of inquiry to a segment of data that relates to a specific research question (Saldana, 2016). Similarly-coded segments are then collected together for more detailed analysis. According to Saldana, structural coding is particularly applicable to qualitative studies that engage multiple participants and have semi-structured data collection protocols, which this study employs (2016). Structural coding is effective in allowing a researcher to categorize commonalities within the data corpus and within the codes (Saldana,
2016). Each question in the interview protocol was coded separately, meaning that all 40 responses to question 3 were coded together, and all 40 responses to question 10 were coded together, and so on, in order to ensure consistency in coding across all of the participants. Each question had unique codes that started with the question number, then the broader category, then the specific category. For example, in question 14 if a participant mentioned that they recognized their team as a group with email recognition, this was coded as “14_Group_Email”. The full code list is listed in the appendices. But all code frequencies are discussed previously in Chapter
4 in the graphical illustrations and discussions.
The data analysis for the interview questions discussed in this section was primarily complete utilizing Microsoft Excel software and ATLAS.ti coding software. The interviews were transcribed via handwritten notes on the interview protocols during the interviews. These were transcribed electronically into excel for each participant and for each question individually.
Questions 1, 2, and 11 from the interview protocol were analyzed using Excel calculations.
Questions 3 through 18 were analyzed using the ATLAS.ti qualitative coding software. Each
86 question was coded using broad and narrow categories in the software, and were also grouped into themes by the researcher within the software as well. The data visualizations were produced in Microsoft Excel using the code frequencies from ATLAS.ti translated into Microsoft Excel visualizations to better explain the themes and code frequencies.
Themes
Themes within the data were identified both by grouping codes into broader categories and themes within each question, as well as by finding commonalities in the themes between all of the questions together after the data was coded. Several themes and trends were discussed in the data analysis above. The primary two themes that arose out of all of the commonalities between questions were first that corporate and organizational challenges and pressures were the largest detractors to motivation in the teams. This was demonstrated in Figure 11, Figure 13, and
Figure 17 earlier in Chapter 4. A trend in responses showed that organizational and corporate changes within the health system were most significantly impacting declines in motivation, and at the same time, organization-wide and corporate efforts to increase motivation were primarily ineffective. The second primary theme that was identified was that the most significant drivers of motivation revolved around personal relationships and connections between leaders and followers, and inter-team relationships. Broader organizational motivational efforts were less impactful on the themes. This was demonstrated in Figure 11, Figure 12, Figure 13, and Figure
17 earlier in Chapter 4 and is summarized in Figure 20 below.
The most frequently mentioned drivers of rural healthcare employee motivation that were mentioned were primarily relating to personal connections between leaders and followers (listed in Figure 12). A trend emerged showing that these personal relationship-based drivers of motivation had stronger impacts on increasing motivation than the organizational or more 87 corporate motivation efforts. That trend continued on to show that the effectiveness rating of the personal relationship-based motivational improvement methods were more effective compared to the broader corporate organizational motivational approaches (depicted in Figures 17 and 18 previously).
Figure 20. Themes
Validity and Reliability
Member-checking of transcribed participant answers is the process of consulting participants of the study to verify the transcribed version of their qualitative interview (Saldana,
2016). Verification of the reliability of the interview transcriptions was requested by the researcher from each participant after each question that the participants answered. The notes that were taken by the researcher were reviewed with the participant after each question. This was an important step to offer the opportunity to ensure the researcher fully captured what the participant expressed in their response. Once the reliability confirmation was completed, the researcher and participant moved onto the next question in the interview. Member checking ensured that the transcribed answers from each participant were reliable and consistent with the participants’ individual thoughts on each question. Validity of the coding was ensured by allowing to reflect on the research between steps in the data collection and analysis steps. This allowed for the researcher to transcribe, code, and develop themes from the data as clearly as 88 possible. Organization and consistency were ensured within the ATLAS.ti software by ensuring that similar codes were being used for the same things, even through interviews one through forty. Checks were performed by looking at the quotes that were within each code utilized in
ATLAS.ti. This validation step was to verify that no codes had been added to quotes erroneously, and that interviews were being consistently from the beginning to the end of the coding process.
Summary
In conclusion, qualitative data was collected consistent with the approved methodology in order to attempt to answer the research question focused on leadership behaviors are most impactful on developing a motivated workforce within a rural healthcare system in South-Central
Pennsylvania. 40 semi-structured interviews were completed, and structured postcoding was used to code the data and analyze the data. Themes that emerged from the data collection and coding indicated personal relationship-based approaches to motivation and personal connections with leaders are impactful in building a more motivated workforce in a rural healthcare setting.
The discussion section will discuss the impact of these findings, and any correlation between these findings and previously completed research in other areas of healthcare.
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CHAPTER V
DISCUSSION
This chapter will discuss the findings of the study, the impact of the data and data analysis from Chapter 4, challenges with the research study, as well as provide recommendations to future researchers who choose to perform studies in a similar environment. This chapter will also discuss correlations between the findings of this research study and other studies that have been performed in the field.
Summary of Study and Findings
This study was developed and conducted to research the connections between leadership behaviors and employee motivations in rural outpatient and ambulatory clinical settings. Because this research was conducted within a gap in the current academic environment, the research was novel and was developed to be as comprehensive as possible. According to Neutens & Rubinson
(2013) and Pope (2020), a major strength of qualitative research in healthcare is that this type of methodology is well-suited for studying people, their actions, and their perceptions in true, real- world environments instead of experimental environments. There is an aspect of “naturalism” included in qualitative methods, which Pope describes as depending on interacting with participants in their own territory, using their own language, and doing so on their own terms
(2020). The participant perspective, or how people live their lives and make sense of their worlds, is of the utmost importance in qualitative data collection.
Utilizing a qualitative case study design, and employing a semi-structured interview protocol, allowed the researcher to gather data that is in-depth, comprehensive, and clear. Each of the semi-structured interviews were conducted solely by the researcher, and were individual interviews with each participant separately. The site where this research was conducted was 90 within a comprehensive health system in the South-Central region of Pennsylvania. This health system had an expansive outpatient footprint, and provides care to primarily rural geographies.
The outpatient service line allowed for access to a large group of participants in leadership roles whom hold similar roles and perform similar functions. The semi-structured interview contained a core of structured questions from which the interviewer may move in related directions for in- depth probing (Neutens & Rubinson, 2013). This implementation of semi-structured interviews was appropriate in the case of this research due to the need to gather in-depth data from each participant, and the semi-structured approach allowed the researcher to ask probing questions if a particular answer from a participant is vague, or of more details are needed to completely answer the questions.
Out of the 90 potential participants, the goal was to interview 25-35% of the group (23-32 subjects in total). At the conclusion of the data collection for this study, 40 participants had agreed to participate and were interviewed. Saturation occurred during the collection of the interview data. As described by Saldana (2016), saturation occurs when no new information or trends seem to emerge during the collection and coding of the data. Based on some of the answers that became relatively repetitive after the 35-interview mark, it can be assumed that saturation for this population occurred before the 40th interview was conducted. After the interviews were conducted, the data was transcribed by the researcher into Microsoft Excel, and then coded in ATLAS.ti software.
A primary theme that was identified after the analysis was that the most significant drivers of motivation were personal relationship-based aspects, and were less significantly connected to the organization or corporate initiatives focused on improving staff motivation.
This was demonstrated in Figure 11, Figure 12, Figure 13, and Figure 17 in Chapter 4. The most
91 frequently mentioned drivers of rural healthcare employee motivation that were mentioned were primarily relating to personal connections between leaders and followers (listed in Figure 12). A trend emerged between personal leader-follower relationship drivers of motivation being stronger drivers than organizational drivers of motivation. That trend continued on in the effectiveness rating of the personal manager-implemented approaches to improving motivation compared to the organizational corporate approaches to improving motivation (depicted in
Figure 18 and Figure 18) where leaders described most frequently that personal connections and motivational techniques were the most effective. Because these trends were identified in the data provided by the study participants, an additional analysis was completed after the research was conducted.
Findings Related to Literature
As discussed in Chapters 1 and 2, this study was developed to help fill a gap in research surrounding leadership behaviors that impact employee motivation in outpatient ambulatory clinical settings in rural healthcare. As depicted in Figure 1, there are a multitude of challenges facing rural healthcare delivery, and employee motivation is only a part of that overall challenge.
After the study was completed and the data set was analyzed, additional literature research was completed to identify similar and differential relationships between the actual findings of this study, and existing studies that have been published. This analysis was conducted in addition to the comprehensive literature review discussed in Chapter 2.
Because of the overall themes that emerged from this study which pointed toward personal relationships between leaders and followers being most motivational to rural healthcare employees, it can be correlated that leadership styles embracing these personal connective approaches would be most effective in leading teams of rural healthcare employees such as the 92 participant group from this study. One leadership style that embraces a very humanistic and personal touch regarding leading is the transformational leadership approach. The transformational leadership theory describes these significant leadership traits very well.
Transformational leaders are driven by personal connections, and aim to resolve barriers in the organization (Roberts, Hacker, & Beigel, 2010). Transformational leaders, according to Roberts,
Hacker, & Beigel, also aim to develop new leaders and expand employees’ capabilities. This aligns well with one of the identified drivers of motivation in this research study which was upward mobility and opportunities for growth and advancement professionally (depicted in
Figure 12 in Chapter 4).
The results of this study were also analyzed against previously-completed dissertation research to look for correlations between the population studied in this research and other fields and environments. One dissertation in particular focused on rural leadership in industrial environments, and concluded that the personal approaches to leading followers taken by transformational leaders were more effective in underserved rural areas than were other leadership styles (Beck-Tauber, 2012). Beck-Tauber found that leadership influence was built on relationship-building and a positive personal connection with the group of followers (2012).
While Beck’s study does not focus on healthcare, it does provide a cross-reference to other industries where effective leaders in rural settings have shown to be most effective when employing personal relationship-building through leadership styles such as transformational leadership.
A leadership theory that may not align well with the results of this study is the more traditional transactional leadership style. One major difference between transactional and transformational leadership discussed earlier is the idea of where organizational success is
93 derived from. In more traditional transactional theories, the sole providers of organizational success are from farther up the “ladder” from leaders (Irving, 2017). Conversely in servant leadership, the focus is in the opposite direction; instead, servant leaders see their followers as the sole drivers for organizational success and for the meeting of organizational goals (Irving,
2017). Servant leadership has been strongly linked to higher job satisfaction and organizational performance in the healthcare sector as a whole (Irving, 2017). Based on the similarities and differences between leadership styles and the results of this study, transformational or servant leadership theories seem to align most closely with the personal and involved nature of leaders who are successfully motivating employees in rural ambulatory healthcare settings from this research study.
Study Challenges
One of the challenges faced early on in the study was the added restrictions that came along with the COVID19 pandemic. Researching in a pandemic was a new challenge not only for the researcher, but also for governing bodies such as the IRB, and Universities alike. The restrictions caused a roughly 90-day delay in the start of the research, which created a much more condensed timeline to complete the data collection and all steps after the collection of the data. Outside of timeline adjustments, the primary methodological change to the study, driven by the COVID19 pandemic, was the transition from in-person to virtual interviews. The original methodology planned for face-to-face interviews between the researcher and the participants; this plan was changed to virtual interviews as discussed in Chapter 3.
Additionally, challenges were faced due to this research being governed by two separate
Institutional Review Boards. This study had to abide by IRB requirements at the University, as well as at the health system where the study participants were recruited from. Both review boards 94 had similar overall requirements for the methodology, but there were discrepancies in the requirements for developing the consent forms, recruitment communications, and the principal investigators’ roles in the research. These discrepancies were rectified through collaboration, but it was a time-consuming process.
An additional unexpected challenge after the research was complete was the management of an overwhelming amount of data. This study methodology section aimed to achieve a 25-35% participation rate (23-32 interviews), which was exceeded by 40 interviews in total being conducted for the research. As described above, saturation occurred around the completion of 35 interviews. But due to the overwhelming response to the initial round of recruitment communications, all respondents who were interested in participating in the study were able to study. While this created a very rich and robust data set, it created an overwhelming amount of data to transcribe, and to code after the transcriptions. This time was not originally planned, and created a tense timeline. However, the resulting data and themes from that data proved to be valuable.
Limitations of the Study
This qualitative research study aimed to collect data that was as comprehensive and beneficial to the body of knowledge as possible. Because the study was conducted within a single healthcare organization, the results are not able to easily be generalized to a larger population of healthcare organizations. Additionally, the study was conducted in one rural geography within the US, which was in south-central Pennsylvania. However, recommendations can still be made to other healthcare organizations that are facing similar challenges with employee motivation and leadership in rural clinical settings to assist in the development of more effective communication methods to better motivate the staff within the health systems. Future
95 studies may choose to either involve a larger sample of rural healthcare systems in the study, or involve more rural geographies throughout the US in order to generalize the results to a larger population. Participants in this study were also all in leadership roles which limited the perspectives to leaders on the topic of motivation. According to Aarons et al. (2017), there may be discrepancies between the perceptions of leadership from a leader’s perspective and a follower’s perspective. An assumption of this study was that the participant leaders had an understanding of techniques that motivated their specific teams the most. A quantitative approach in future studies may be able to include perspectives of both leaders and followers to potentially statistically measure the connections between leaders and the individual employees they manage.
Recommendations for Future Research
After completing this qualitative semi-structured interview study, it became clear that there is a connection between personal connections of leaders and followers in rural healthcare settings and motivation in those settings. To gain a better understanding of the significance of those important relationships between leaders and followers, future researchers may consider quantitative analysis for significance factor between leadership styles and the motivation levels that they produce. Due to the findings of this study, future researchers may also consider a more narrowed study focusing strictly on personal attributes of leadership in rural healthcare, and how those personal attributes of leadership can be better employed in management within rural healthcare settings. This study may help future researchers to perform even more specific and valuable studies in a similar field. The limitations previously discussed of this study also present opportunities to develop future and more expanded research incorporating multiple healthcare organizations and geographies.
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Summary
In summary, this study was conducted as a way to gather and synthesize knowledge, perspectives, and data to help to fill a gap in the currently-published literature. This study allowed for the researcher to collect data from healthcare leaders in outpatient clinical settings regarding the motivational successes, barriers, and strategies currently being deployed on the front lines. With the large pool of research subjects who agreed to participate in the qualitative semi-structured interviews, a comprehensive and thorough data set was able to be compiled and analyzed at the conclusion of the research. A multitude of trends and insights were discovered and discussed in chapter four. Themes that emerged from the data collection and coding indicated personal relationship-based approaches to motivation and personal connections with leaders are impactful in building a more motivated workforce in a rural healthcare setting. The more personal and relationship-focused of an approach a manager takes to interacting with and motivating their employees, the better results will be seen in the positive changes within those employees. This new knowledge can help current healthcare managers and organizations to devise plans to engage and motivate their frontline teams, and this research study can also serve as a foundation for future researchers in the field to build their studies off of.
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APPENDICES
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APPENDIX A
Interview Protocol
Introductory Protocol:
I have provided you with the Institutional Review Board-approved consent form via email.
Please review this and ask any questions that you have. This form contains the basic information about the study and describes that all information will be held confidential, your participation is voluntary, and you may stop at any time, and there is little to no risk in participating in the study.
Your participation in the study implies your consent to the study. This interview is scheduled for
30-minutes, and we have several questions to cover during that time.
Introduction:
Based on your job title from the inclusion criteria, you either have the title of Senior Practice
Manger or Practice Manager within the health system. This interview is aimed at collecting data to analyze trends within the relationships between leaders and followers in outpatient settings in the health system and how frontline employees are most effectively motivated. Please feel free to answer questions honestly with positive, negative, or neutral feedback and responses. This study does not aim to evaluate any of your techniques or experiences, but focuses solely on learning more about interactions between leaders and followers and how frontline employees are effectively motivated.
Interview Questions:
Interviewee background:
1. How long have you held a leadership position (including your current position and any
previous leadership roles)?
2. What is your degree and field of study?
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Leadership Style:
1. If you were to describe your approach to interacting with employees on a daily basis, not
necessarily coaching, but just general interactions, how would you describe that approach?
2. If you were to describe your approach to interacting with employees when coaching for
performance improvement, how would you describe that interaction? Is it the same for every
employee?
3. What are three things that, in your opinion, your employees would associate with your
leadership style? Just three traits, not necessarily an in-depth explanation.
4. When delegating tasks to your employees, what is your go-to process as to how you
communicate the delegation of the work, and also ensuring that works gets done properly?
5. How do you generally support employees who are interested in becoming leaders in the
future? Have you successfully coached any employees into moving from frontline to
leadership positions while you’ve been in your role?
Motivating employees:
1. In a general perspective, how motivated would you say your teams are? Clarification: they’re
willing to put in the effort to get the job done, get it done correctly the first time, and ensure
they are performing the best that they possibly can be.
2. If you were to give a general percentage, what proportion of your employees would you say
are proactive in their roles, as in they independently take steps to avoid an issue from
happening instead of reacting after it happens?
3. What are the top three things, from your individual perspective, that you think contribute
most to how motivated your teams are working in rural healthcare?
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4. What are the top three things, from your individual perspective, that you think are barriers to
your employees becoming more motivated in their roles within rural healthcare settings?
5. How do you normally reward employees to recognize positive behavior? (i.e. verbal,
incentives, recognition, group-setting, monetary, none, etc.)
6. How would you describe the effectiveness of motivational strategies that have been
implemented across the rural health system?
7. How would you describe the effectiveness of motivational strategies that you have personally
implemented with your specific team?
8. What other insight or information would you like to share that is relevant to the study but that
we may not have discussed during this interview so far?
Post-interview comments, suggestions, observations, etc.:
Conclusion:
Thank you for taking a few minutes out of your day to participate in this research study. I have provided you with my contact phone number and email, and if at any time after this interview you have any questions about the study or its status, please feel free to contact me.
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APPENDIX B
Subject Recruitment Communications
Recruitment of the participant population will primarily come in the form of email commutations sent to potential participants. These participants are chosen from the employee listing, based on the inclusion criteria of having titles of Practice Manager or Senior Practice Manager. If study participation is low, follow-up emails will be sent to potential participants again, reminding them that the study is ongoing, and reinforcing the benefits of participating in the study. An announcement may also be given, by the researcher and Principal Investigator, at a Practice Managers’ quarterly meeting. A script for that is below as well. Initial email communication announcing that the study will be occurring: This email will come the Chief Operating Officer of the Health System. Good morning, An upcoming research study is going to be conducted by Tyler Chrest, who currently works within our service line. He is conducting research within our health system to complete his dissertation for his Doctorate degree. This research is approved by the Emig Research Center, and is also being supervised by his manager. I support Tyler’s research and I believe it will provide valuable insight into the impacts that all of our managers have on the motivation of frontline employees within the health system. He will be reaching out to you to participate in the study. It should only take about 20 minutes, and can be done over the phone or in-person at a convenient location. Your participation is anonymous as Tyler is only collecting group data across our system as a whole. I am hopeful that you will give a few minutes of time to participate in Tyler’s research study to benefit him in his academic journey, as well as benefit the health system by providing insight into our strategies to best motivate and engage frontline teams. Initial email communication to invite participants to take part in the study: This email will come from K. Tyler Chrest, researcher, inviting the participants to participate. Good morning, I am reaching out to you this morning to invite you to participate in a research study on the impacts of leadership styles on frontline employee motivation within the health system. As a leader yourself, you have the opportunity to provide insightful data to the study in order to better understand how employees are best motivated in the outpatient setting. We are gathering information from leaders in the medical group on what strategies they find the most effective in motivating their teams, regardless of how many people you have direct supervision over. The information collected from these conversations is anonymous, and is only contributing to a larger ‘pool’ of data as a whole. Names, positions, dates, times, etc. are not recorded at all so that you can remain anonymous in your answers. You’ll be contributing to a group dataset that allows for the analysis of trends on how you best motivate your frontline staff in your daily team management. Participation in the research takes at most 20-30 minutes, and we can have the conversation either over the phone, or in-person, whichever is easiest for you. If there are times of day that
102 work best for you, or in the mornings or evenings, certainly let me know. I will be flexible to what suits your schedule best. I am looking forward to hearing back from you. Please let me know if you have any initial questions, and if you’re willing to participate in the research, let me know and I will get a time scheduled on our calendars. Follow-up email communication (only to be sent after 14-days, if participation is below the percent of participation needed for the study). This email will come from K. Tyler Chrest, researcher. Good morning, this email is to follow-up on the initial invitation that we sent to you regarding participating in the study entitled “Case Study Researching the Impacts of Leadership Styles on Frontline Employee Motivation in a Health System”. We haven’t received a response from you, and we would like to answer any questions that you have about participation in the study. To participate in the study, please simply reply back to this email and let me know of your interest, and I will schedule a time on our calendars to conduct the interview.
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APPENDIX C
Informed Consent Forms
Informed Consent to Participate in Research Study Title: Case Study Researching the Impacts of Leadership Styles on Frontline Employee Motivation in a Health System Principal Investigator: Brent A. Doores, MBA Co-Investigator/Researcher: K. Tyler Chrest, MHS
We are asking you to be in a research study. You do not have to be in the study. If you say yes, you can quit the study at any time. Please take as much time as you need to make your choice. By completing this interview you are implying your consent to do so. Why are you doing this research study? We want to learn more about how to help people who have leadership styles and the motivation of frontline employees in outpatient settings. This study will help us learn more about current leaders in the health system and how employees are most effectively motivated from their perspective. We are asking people who are leaders within the health system to help us. What happens if I say yes, I want to be in the study? If you say yes, we will: • Conduct an interview with you to ask about your current leadership position, your approaches to leadership, and how motivating your employees plays into your role as a leader. There are no right or wrong answers to these questions. You can skip any question you do not want to answer. How long will the study take? The study will take about 15-30 minutes of your time. What happens if I say no, I do not want to be in the study or if I change my mind later? No one will treat you differently. You will not be penalized. Who will see my answers? The only people allowed seeing your answers will be the people who work on the study and the people who make sure we run our study the right way. We are not collecting your name or any other identifiers for this study. We will do our best to make sure no one outside the study will know you are a part of the study. Will it cost me anything to be in the study? There are no costs associated with participating in this study. Will being in this study help me in any way? No. There is no direct benefit to you by participating in this study. Your participation will help us to better understand how frontline employees are most effectively motivated in their working environments. Will I be paid for my time? You will not be paid for participating in this study. Is there any way being in this study could be bad for me? There are no risks associated with participating in this study.
What if I have questions? For more information about this study or if you experience any injury or illness please contact:
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K. Tyler Chrest (Researcher/Student) and/or Brent A. Doores (PI/Sponsor)
Please contact the Franklin University IRB at (614) 947-6037 if you have questions, complaints or concerns about the study or if you have questions about your rights as a research participant.
Your permission (consent) to participate in this study is implied by your participation.
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APPENDIX D
Subject Matter Expert Letters
Initial Communication to SMEs from Researcher:
Good morning, I hope you’re doing well. I am reaching out to see if I could gain some insight from your expertise in leadership development for my upcoming dissertation research project. I’m working on a dissertation project which will be conducted within the health system for my degree, and I’ll be starting the research in early next year. The project will be going through approval through the Research Center internally as well. The overall focus is the impact of leadership styles on frontline employee motivation in outpatient settings. As part of that, I am developing a data collection tool, which in this case is a qualitative interview protocol, and that tool will require validation from industry experts on the topic. This would require a comprehensive review of the interview layout, individual questions, additions/adjustments to questions, and the addition of other perspectives not already included but would be beneficial to the study. Let me know if you would be willing to provide me with some insight! If so, can I set up a meeting on our outlook calendars to discuss early in the new year? Thanks in advance! Tyler
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Letters of Support from Subject Matter Experts:
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APPENDIX E
Data Codes from ATLAS.ti Coding Software
Section Ques General Category Specific Associated Code tion Category Num ber Leadershi 3 Personal Morning 3_Personal_Morningrounding p Style Interaction Rounding Multiple 3_Personal_Multiplecheckins Checkins Transparent 3_Personal_Transparent Communicatio n Open Door 3_Personal_Opendoor Policy Informal 3_Personal_Informal Conversations Non-Personal Daily Huddle 3_Nonpersonal_Dailyhuddle Interactions Calls Daily Emails 3_Nonpersonal_Dailyemails Sent to Staff Staff Inclusion Staff included 3_Staffinclusion_decisionmaking in decision making Empowerment 3_Staff_Empowerment 4 Personal Feelings Dislike these 4_Feelings_Dislike Towards conversations Coaching Enjoy these 4_Feelings_Like conversations Conversation In private 4_Setting_Private Setting space In employee’s 4_Setting_Public work area Delivery Conversational 4_Delivery_Conversational Non- 4_Delivery_Nonconfrontational confrontational Direct 4_Delivery_Direct Deliver 4_Delivery_Confident confidently Proactive 4_Delivery_Proactive approach Set or Discuss 4_Delivery_Expectations Expectations 109
Positive 4_Delivery_Positive conversation Bring second 4_Delivery_Secondperson person Approach Custom for 4_Approach_Custom each employee Same for every 4_Approach_Same employee 5 Descriptive words Honest 5_Honest of leader Trustworthy 5_Trustworthy Kind 5_Kind Understanding 5_Understanding Flexible 5_Flexible Compassionate 5_Compassionate Fair 5_Fair Calm 5_Calm Approachable 5_Approachable Timely 5_Timely Fun 5_Fun Appreciative 5_Appreciative Transparent 5_Transparent Dedicated 5_Dedicated Proactive 5_Proactive Innovative 5_Innovative Collaborative 5_Collaborative Supportive 5_Supportive Mentor 5_Mentor Meticulous 5_Meticulous Assertive 5_Assertive 6 Feelings on Enjoys 6_Feelings_Enjoys Delegation delegation Dislikes 6_Feelings_Dislikes delegation Delegation In person 6_Communication_Personal Communication Email or 6_Communication_Impersonal impersonal Delegation Ask for 6_Communication_Volunteers Communication volunteers Level of Control Choose 6_Communication_Specificemploy of Delegation specific ee employee Micromanage 6_Control_Micromanage Empower the 6_Control_Empowerment employee
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Delegation Informal 6_Followup_Informal follow-up Formal 6_Followup_Formal 7 Active Approach Monthly 7_Active_Rounding rounding Identify 7_Active_Identifyleaders informal leaders Mentorship 7_Active_Mentorship Assign 7_Active_Challenges challenging projects Involve in 7_Active_Involvedecisions management decisions Offer flexible 7_Active_Flexschedules schedules Know 7_Active_Knowgoals employee’s goals Passive Refer 7_Passive_Referhr employees to HR Wait for 7_Passive_Waitemployees expressed interest Refer to 7_Passive_Referexternal another department Promote 7_Passive_Externaleducation external education Promote 7_Passive_Internaleducation internal education 8 Connected to Personal 8_Connected_Personal Manager growth and development Job or task 8_Connected_Task related improvement Received 8_Connected_Advice advice Disconnected Frequent 8_Disconnected_Frequentchange from Manager manager changes 111
Never received 8_Disconnected_Nofeedback any feedback 9 Most Important in Clear 9_Clearcommunication Effective communicatio Leadership n Leading by 9_Leadexample example Authenticity 9_Authenticity Availability 9_Availability Trusting 9_Trusting relationships Flexibility 9_Flexibility Know 9_Knowpersonally employees personally Employee 10 Current status of Positive or 10_Positive Motivatio team’s motivation High n as a whole motivation level Mixed 10_Mixed motivation levels, or indifferent Negative or 10_Negative Low motivation level 12 Personal Recognition 12_Personal_Managerrecognition from manager Inclusion in 12_Personal_Inclusion decision- making Teamwork and 12_Personal_Teamdynamics team dynamics Work 12_Personal_Workenvironment environment Positive 12_Personal_Patients patient interactions Positive 12_Personal_Providerfeedback provider feedback Organizational Pride in 12_Organizational organization _Prideorganization
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Growth 12_Organizational_Growth opportunities Committees & 12_Organizational_Committees pilot programs Compensation 12_Organizational_Compensation 13 Personal Outlier 13_Personal_Outliers employees Staff conflict 13_Personal_Conflict Manager 13_Personal_Managerexpectations expectations Personal issues 13_Personal_Personalissues at home Lack of 13_Personal_Involvement involvement in decisions Patient 13_Personal_Patients feedback Organizational Compensation 13_Organizational_Compensation Constant 13_Organizational_Constantchange changes s Budget 13_Organizational_Budgetreductio reductions ns Lack of 13_Organizational_Growth growth opportunities 14 Group At staff 14_Group_Meeting Recognition meetings Group emails 14_Group_Emails Team food 14_Group_Food Team event 14_Group_Event Personal At staff 14_Personal_Meetings Recognition meetings In person 14_Personal_Individually individually Handwritten 14_Personal_Cards cards Small gifts 14_Personal_Smallgifts Customized to 14_Personal_Customized the employee 15 Not Effective Cumbersome 15_Ineffective_Cumbersome Perceived as 15_Ineffective_Shallow shallow or hallow Overwhelming 15_Ineffective_Overwhelming
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Communicated 15_Ineffective_Communicatedlate too last minute Mixed Some 15_Mixed_Workedforsome Effectiveness responded positively, some did not Effective Positively 15_Effective_Positive received Encouraged 15_Effective_Collaboration collaboration Boosted 15_Effective_Boostedmotivation motivation 16 Effective Personal or 16_Effective_Personal verbal recognition Material 16_Effective_Material recognition Boosts 16_Effective_Boostsmotivation motivation Mixed Some respond 16_Mixed_Worksforsome Effectiveness positively, some do not Not Effective Some staff are 16_Ineffective_Complacent complacent 17 Additional Insight None 17_Additional_None Generic/Appre 17_Additional_Appreciative ciative Leadership 17_Additional_Advice advice
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