BHLB
Feature
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
Health care professionals’ motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review Gepke L. Veenstra • Kirsten F. A. A. Dabekaussen • Eric Molleman • Erik Heineman • Gera A. Welker
Background:Health care professionals’workmotivation is assumed to be crucial for the quality of hospital care, but it is unclear which type of motivation ought to be stimulated to improve quality. Motivation and similar concepts are aligned along a motivational continuum that ranges from (intrinsic) autonomous motivation to (extrinsic) controlled motivation to provide a framework for this mixed-methods systematic review. Purpose: This mixed-methods systematic review aims to link various types of health care professionals’ motivation directly and through their work-related behaviors to quality of care. Methods: Six databases were searched from January 1990 to August 2016. Qualitative and quantitative studies were included if they reported on work motivation in relationship to work behavior and/or quality, and study participants were health care professionals working in hospitals in high-income countries. Study bias was evaluated using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. The review protocol was registered in the PROSPERO database (CRD42016043284). Results:A total of 84 out of 6,525 unique recordsmet the inclusion criteria. Results show that health care professionals’ autonomousmotivation improves their quality perceptions andwork-related behaviors. Controlledmotivation inhibits voicing behavior, but when balanced with autonomous motivation, it stimulates core task and proactive behavior. Proactivity is associated with increased quality of care perceptions. Practice Implications: To improve quality of care, policy makers and managers need to support health care professionals’ autonomous motivation and recognize and facilitate proactivity as an essential part of health care professionals’ jobs. Incentive-based quality improvements need to be complemented with aspects that stimulate autonomous motivation.
Keywords: health careprofessionals,mixed-methods systematic review, quality of care,workbehavior,workmotivation
I t is widely assumed that health care professionals’ work motivation is beneficial for the quality of patient care in hospitals (Berenson & Rice, 2015; Franco, Bennett, &
Kanfer, 2002). Health care professionals’ work motivation is increasingly being investigated, as scholars draw on the
Gepke Lolkje Veenstra,MSc, is PhD Candidate, Center of Expertise onQuality and Safety, University Medical Center Groningen, the Netherlands. E-mail: g.l.veenstra@umcg.nl.
Kirsten F.A.A. Dabekaussen, BSc, is MD-PhD Student, Department of Surgery, University Medical Center Groningen, the Netherlands.
Eric Molleman, PhD, is Full Professor, Faculty of Economics and Business, Department of Human Resource Management and Organizational Behavior, University of Groningen, the Netherlands.
Erik Heineman,MD, PhD, is Full Professor, Department of Surgery, Center of Expertise on Quality and Safety, University Medical Center Groningen, the Netherlands.
Gera A Welker, PhD, is Implementation Advisor, Center of Expertise on Quality and Safety, University Medical Center Groningen, the Netherlands.
The authors have disclosed that they have no significant relationship with, or finan- cial interest in, any commercial companies pertaining to this article.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (www.hcmrjournal.com).
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in anyway or used commercially without permission from the journal.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc.
DOI: 10.1097/HMR.0000000000000284
Motivation, Behavior, and Quality: Review
positive effects of motivation on performance that were ob- served in the organizational literature (Cerasoli, Nicklin, & Ford, 2014; Kim, Kolb, & Kim, 2013). However, it is unclear whether these findings apply to the quality of patient care, as studies from the field of organizational research tend to focus on individual-level employee outcomes, such as performance or employee behavior, rather than on team or organizational outcomes (Kim et al., 2013). In a complex system as health care, quality follows from the performance of many indepen- dent actors working together in a connected system, which means that performance at the individual level does not necessarily predict the outcomes of the system: quality of care (Griffin, Neal, & Parker, as cited in Gagné, 2014; Hollnagel, Wears, & Braithwaite, 2015).
The inability to determine whether and how health care professionals’ motivation affects patient care is problematic, because it hampers the development of effective motivation- based policies and interventions to boost care quality. More- over, current motivational strategies may even have unin- tended consequences. For example, financial incentives, which are widely popular in health care (Berenson & Rice, 2015; Flodgren et al., 2011), may improve performance on relatively simple tasks but at the same time hold the potential to “crowd out” intrinsic motivation, which determines the
www.hcmrjournal.com 155
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
quality of performance on complex tasks (Cerasoli et al., 2014). Therefore, more insight is needed in the relationships between health care professionals’ work motivation, their work behaviors, and the quality of care.
Previous attempts to integrate the literature on this topic were unsuccessful in linking health care professionals’ work motivation to the quality of hospital care. In an overview of reviews, Flodgren et al. (2011) concluded that there is some but limited evidence for the effectiveness of financial incen- tives in changing professional practice, but no evidence to support any effects on patient outcomes. Likewise, systematic reviews on nurses’ work engagement and physicians’ occu- pational well-being reported positive associations with work behaviors, but the link with care outcomes was understudied (Keyko, Cummings, Yonge, & Wong, 2016; Scheepers, Boerebach, Arah, Heineman, & Lombarts, 2015).
This review aims to go beyond existing work to get more insight in the relationship between motivation and quality of care. To achieve this aim, we apply a broad approach by synthesizing the evidence from quantitative and qualitative studies on (a) the direct relationships between autonomous motivation, controlled motivation, and amotivation of all health care professionals involved in direct patient care in hospitals and the quality of hospital care, (b) the relationships between these types of work motivation and health care pro- fessionals’ core task and (c) proactive behaviors, and (d) the relationship between proactive behaviors and the quality of patient care in hospitals. To overcome a potential lack of ev- idence due to narrow conceptualizations of work motivation and work behavior as observed in previous reviews, we use ex- tensive conceptualizations of these constructs by considering similar concepts, which we place within a theoretical frame- work to guide our systematic search for evidence and the
Figure 1. Theoretical framework: motivational continuum and Res
156 Health Care Manage Rev • April-June 2022 • Volume 47 • Number
synthesis of results. The theoretical framework and research questions are depicted in Figure 1 and will be further ex- plained subsequently.
Background Motivation Work motivation is defined as “a set of energetic forces origi- nating within and beyond an individual’s being, which deter- mines the form, direction, intensity and duration of work- related behavior” (Pinder, as cited in Gagné, 2014, p. 38). Ac- cording to the self-determination theory, various forms of work motivation exist on a continuum (Deci & Ryan, as cited in Gagné, 2014). This continuum ranges from autonomous moti- vation at the one end, through controlled motivation, to amotivation at the other end of the continuum. Autonomous motivationmeans that the reasons to engage in a behavior stem from within a person. From most autonomous to least autono- mous, a behavior can be perceived as enjoyable or interesting in itself (intrinsic motivation), or as an integral part of oneself (integrated regulation), or the values underlying the behavior can be considered congruent with one’s personal goals and identity (identified regulation). Controlled motivation means that reasons to engage in a behavior stem from beyond a person. When driven by controlled motivation, a behavior is done be- cause it has instrumental value; it helps to obtain a sense of self-worth or prevents one from feeling guilty (introjected reg- ulation) or it leads to a separable outcome such as money or status (external regulation).Amotivation refers to not being mo- tivated to engage in an activity (Deci & Ryan, as cited in Gagné, 2014).
From this perspective, we align several related constructs that refer to energetic forces that guide behavior with this motivational continuum to guide our review. From most to
earch Questions (RQ) 1–4
2 www.hcmrjournal.com
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
least autonomous, we consider work engagement (“a positive affective-motivational state of work related well-being”; Bakker et al., as cited in Kim et al., 2013, p. 249), psychological empowerment (intrinsic task motivation due to finding the task meaningful and experiencing self-efficacy and a sense of impact; Thomas & Velthouse, as cited in Gagné, 2014), psychological ownership (being psychologically tied to an ob- ject as an extension of one’s identity, e.g., the organization, or the patient; Van Dyne & Pierce, 2004), affective commit- ment (“a force that binds an individual to a course of action relevant to one or more targets,” e.g., the job, organization or patient, based on values, personal involvement, and iden- tity; Meyer & Herscovitch, as cited in Gagné, 2014, p. 34), and finally job and work involvement (the importance of one’s job or work in general; Kanungo, as cited in Gagné, 2014).
At the controlled side of the continuum, we consider nor- mative commitment (an attachment to a target based on a per- ceived obligation; Meyer & Herscovitch, as cited in Gagné, 2014) and continuance commitment (an attachment to a target based on a cost–benefit analysis of maintaining versus with- drawing from the commitment; Meyer & Herscovitch, as cited in Gagné, 2014).
Finally, a construct that is often used to predict behavior is behavioral intention, which refers to a willingness to exert effort to achieve something (Ajzen, 1991). This construct can be interpreted as the absence of amotivation. To enhance read- ability, the concepts at the autonomous side of the contin- uum are referred to as autonomous motivation, and the concepts corresponding with the controlled side are referred to as controlled motivation. When relevant, specifications are given.
Quality of Care The main aim of this review is to understand the impact of health care professionals’ work motivation on the quality of care. Quality of care encompasses more than just one type of outcome. Following theWorld Health Organization, qual- ity is defined along six dimensions: effectiveness (congruent with current medical evidence and leads to improved health outcomes), efficiency (optimal and sustainable use of personnel and resources), accessibility (timeliness and skills and resources match themedical need), patient-centeredness (respects for indi- vidual needs and preferences of the patient), equitability (equal- ity despite gender, ethnicity, or socioeconomic status), and safety (minimized risk and harm to patients; World Health Organization, 2006). This review aims to shed more light on ResearchQuestion 1: “How do autonomous motivation, con- trolled motivation, and amotivation relate to the six dimen- sions of quality of hospital care?”
Work Behaviors Health care professionals’ actions within a hospital system are the core of patient care. For this reason, it is meaningful to con- sider health care professionals’work behaviors as mediators be- tween motivation and quality of care (Franco et al., 2002).
Work behavior can be classified into two types, namely core task behavior and proactive behavior (Kim et al., 2013; Van Dyne & Pierce, 2004). Core task behavior refers to the
Motivation, Behavior, and Quality: Review
behaviors to fulfill formal task requirements (Crant, as cited in Gagné, 2014), which is similar to role prescribed (or in-role) behavior (behavior that is recognized by the formal reward system and that is part of the job description; Borman & Motowidlo, as cited in Kim et al., 2013). Examples of core task behaviors are guideline adherence and compliance to organiza- tional procedures and protocols (Gagné, 2014). Studies using these concepts are included in our review in order to answer ResearchQuestion 2: “How do autonomous motivation, con- trolled motivation, and amotivation relate to health care pro- fessionals’ core task behaviors?”
Many core task behaviors are formalized in evidence-based guidelines and protocols, which are specific per discipline within the hospital and grounded in ample scientific evidence (Greenhalgh, Howick, & Maskrey, 2014). Consequently, the relationship between core task behaviors and quality of care is too extensive for this review. Yet, it can be argued that, al- though there are exceptions, exerting these behaviors contrib- utes to care quality.
Proactive behavior, the second type of behavior, refers to challenging current circumstances and taking initiative to create new ones and is also described as going beyond one’s job or task requirements (Gagné, 2014). Similar concepts are extra-role behavior (positive and discretionary behavior that is not prescribed in formal job descriptions; Borman & Motowidlo, as cited in Kim et al., 2013) and organizational cit- izenship behavior, which refers “discretionary work behaviors that contribute to organizational well-being but are not part of formal job expectations” (Organ, as cited in Van Dyne & Pierce, 2004, p. 446). Examples of proactive behaviors are en- gaging in quality improvements and voicing concerns or speaking up in unsafe clinical situations (Gagné, 2014). We include these concepts in our review to determine their moti- vators, asResearch Question 3 states: “How do autonomous, controlled, and amotivation relate to health care professionals’ proactive behaviors?”
Health care professionals’ proactive behaviors are indis- pensable for quality of care, as the complexity of the health care system can never be completely captured in guidelines and protocols (Greenhalgh et al., 2014; Hollnagel et al., 2015). However, proactive behavior may have inconsistent contributions for each of the six dimensions of quality. For example, patient-centeredness is likely to increase when health care professionals “go the extra mile” for their pa- tients, but this may diminish efficiency. Therefore,Research Question 4 states: “How do health care professionals’ proac- tive behaviors relate to outcomes on the six dimensions of quality of hospital care?”
Methods In line with the broad approach of this review, a mixed- methods systematic review was conducted. Reviews can be mixed by including various types of studies, by applying mixed methods for the synthesis of studies, or by applying both theory building and theory testing modes of analysis (Harden, 2010). This systematic review was mixed in the sense that we included qualitative, quantitative, and mixed- methods studies. This systematic review was registered in
www.hcmrjournal.com 157
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
the International Prospective Register of Systematic Reviews (PROSPERO, No. CRD42016043284) of the University of York. The data were managed using a PRISMA-based Excel workbook and ATLAS.ti, Version 8.3.2.
Sources and Search Strategy An elaborate search string was entered into PubMed, PsycINFO, Business Source Premier, CINAHL, EMBASE, andWeb of Science. Two librarians (frommedical and social sci- ences departments) were consulted for the development of the search string, which combined three key themes: motivation/ behavior (e.g., motivation OR engagement OR proactive behav- iorOR guideline adherence), health care professionals (e.g., nurse ORphysicianOR resident), and quality of care (e.g., effectiveness OR safety). The search was limited to studies published in an academic journal between January 1990 and August 2016 and written in the English language. The full search string is available from the first author on request.
The search string identified a large number of records, which included all relevant references obtained from related reviews. Consequently, it was considered appropriate to devi- ate from the research protocol by not performing a backward reference search.
Study Selection To be eligible for inclusion in the systematic review, a paper had to match the following criteria: be an empirical quantita- tive or qualitative paper revealing information on at least one of the four research questions, study participants were health care professionals providing direct patient care, the study took place within a hospital setting and in a high-income country as classified by the World Bank (The World Bank Group, 2016), because the availability of resources is an impor- tant factor influencing care quality in middle- and low-income countries (Fritzen, 2007). Furthermore, the paper had to report on individual-level self-reported measures of work motivation, whereas the measures of health care professionals’ behaviors and quality of care could take place at either the individual or at the group level and could be either self-reported (e.g., self-reported behavior or perceived quality) or externally assessed (e.g., supervisor-assessed work behavior or outcomes derived from hospital systems).
The interrater agreement for a random selection of 10% of the screened records was unsatisfactory for both the title and abstract and full-text screening (around 0.5). Consequently, we deviated from the review protocol, which describes that the first author would screen the remaining papers. Instead, the complete title and abstract screening and the complete full-text screening were done by two independent reviewers. Inconsistencies were discussed until consensus was reached.
Risk of Bias, Data Extraction, and Synthesis of Results The risk of bias was assessed using the Standard Quality As- sessment Criteria for Evaluating Primary Research Papers (Kmet, Cook, & Lee, 2004), with quality assessment (QA) checklists for quantitative papers (14 items) and for qualita- tive papers (10 items). These instruments resulted in a QA
158 Health Care Manage Rev • April-June 2022 • Volume 47 • Number
score for each paper with a possible range from 0 to 1, with 1 being the highest score. Studies were included regardless of their QA score, which is used to determine the risk of bias across studies and to differentiate between findings from low-quality and high-quality studies (with QAs below and above average, respectively).
The data extraction concerned the research method, sam- ple size, response rate, descriptive information about the par- ticipants, definitions, and operationalizations of the concepts and research findings. The QA and data extraction were per- formed by two independent reviewers for 41.67% (n = 35) of the research papers, where disagreements were discussed until consensus was reached. The correlation between the QAs of the first author and the second reviewers was satisfactory (r = .61, p < .001) and the correlation between the first authors’ initial QA and the consensus decision was high (r = .89, p < .001). Therefore, it was considered appropriate to perform the risk assessment and data extraction of the remaining pa- pers by the first author. The extracted data were entered into a spreadsheet and coded in ATLAS.ti to enable the narrative synthesis of results per research question. In the synthesis of results, we distinguished between findings based on quantita- tive or qualitative evidence. For mixed-methods studies, this categorization was based on the type of evidence about the re- search question presented.
Results The search resulted in the identification of 6,525 unique re- cords, of which 84 records matched the inclusion criteria. A PRISMA flow diagram of the identification and selection of records is given in Figure 2.
Study Characteristics and Risk of Bias The included records on quantitative findings (n = 66) re- ported on four quasi-experimental studies, four time-lagged studies, four mixed-methods studies, six longitudinal studies, and 48 cross-sectional studies. Records reporting on qualita- tive findings (n = 18) reported on three case studies and 15 interview studies. Of all included studies, 46 focused exclu- sively on nurses, 13 focused exclusively on physicians, and 25 studies had participants from multiple professions, includ- ing nurses, physicians, paraprofessionals, and physician assis- tants. Together, the studies included over 102,500 health care professionals.
The QA resulted in an overall mean score of 0.70 (SD = 0.21), withMQAquantitative = 0.71 (SD= 0.19) andMQAqualitative
= 0.70 (SD = 0.27). The QA across studies (available from the first author on request) demonstrated that a potential risk of bias of quantitative studies are the lack of control for confounding factors and the limited definition and/or operationalization of the concepts of interest. For qualitative studies, most frequently observed shortcomings were the lack of reflexivity, the ambigu- ity of the sampling strategy, and data collection and/or analysis.
Seventy-one of the studies reported on one of the research questions of this review, eight studies reported on two re- search questions, four studies reported on three research ques- tions, and one study reported on all four research questions. An overview of the results is depicted in Table 1. For each
2 www.hcmrjournal.com
Figure 2. PRISMA flow diagram of the literature search
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
research question, the findings based on quantitative evidence will be described first, followed by the qualitative findings, which deepen our understanding of the relationships of inter- est. In the conclusions for each research question, reflections are made upon the influence of the quality of the studies.
Each finding (positive, negative, or no association) about Research Questions 1–4 is depicted in Table 1 and papers reporting multiple research findings are represented multiple times. Full references to the included studies are given in Sup- plemental Digital Content 1 (http://links.lww.com/HCMR/ A67). The full descriptions of the study characteristics and findings as depicted in Table 1 are available from the first au- thor on request.
Motivation and Quality of Care The first research question was investigated in 29 studies: 24 studies reported on quantitative evidence and 5 on qualitative evidence. The quantitative evidence showed that autonomous motivation, mostly investigated in terms of work engagement and empowerment, positively influenced overall perceptions of quality. Organizational commitment had mixed (positive and no) effects on perceived quality, and professional commitment
Motivation, Behavior, and Quality: Review
was positively associated with three out of six patient- perceived quality indicators.
Autonomous motivation positively affected safety percep- tions but had no association with the number of safety events. Work engagement was mostly positively associated with per- ceived safety, but one study reported no association. There was no effect of controlled motivation on perceived safety.
Autonomous motivation had mixed effects on perceived patient-centeredness, with some studies finding a positive as- sociation, one study finding no association and one study reporting a negative association. Controlled motivation was negatively associated with perceptions of patient-centeredness.
For the less investigated quality dimensions, behavioral in- tention was positively associated with perceptions of equita- bility. Autonomous motivation positively affected perceived effectiveness and efficiency of care. Furthermore, an other- wise unspecified sense of motivation was not associated with effectiveness, nor with accessibility of care.
The qualitative evidence also supported positive associa- tions between autonomous motivation and perceptions of quality, safety, and patient-centeredness, whereas an absence of motivation was perceived to lead to poor quality of care. An interview study found that physicians’motivation to provide
www.hcmrjournal.com 159
TABLE 1: Overview of findings per research question (first author and year of publication of the reporting study)
RQ Investigated association Positive association Negative association No association
1 Intrinsic motivation –
safety Toode, 2015 Toode, 2015
Internal work motivation – patient centeredness
Papastavrou, 2015a; Suhonen, 2014a
Work engagement – quality
Freeney, 2013a; Lowe, 2012; Shantz, 2016a; Van Bogaert, 2014a; Wong, 2010a
Work engagement – patient centeredness
Lowe, 2012 Rathert, 2009
Work engagement – safety
Prins, 2009a; Shantz, 2016a Rathert, 2009
Psychological empowerment – quality
Leggat, 2010a; Purdy, 2010a
Psychological empowerment – effectiveness
Spence Laschinger, 2014
Ownership – patient centeredness
Harwood, 2007a
Autonomous motivation – patient centeredness
Redfern, 1999a; Schoenfeld, 2016a
Kosmala-Anderson, 2010
Organizational commitment – quality
De Groot, 1998; Tsai, 2011a
Johnson, 2011a
Organizational commitment – effectiveness
Freund, 2007
Organizational commitment – efficiency
McNeese-Smith, 1999
Organizational commitment – patient centeredness
Rathert, 2009
Organizational commitment – safety
Vogus, 2016a,b; Rathert, 2009
Professional commitment – quality
De Groot, 1998; Teng, 2009b Teng, 2009b
Professional commitment – safety
Teng, 2009
Job commitment – effectiveness
Freund, 2007
(continues)
160 Health Care Manage Rev • April-June 2022 • Volume 47 • Number 2 www.hcmrjournal.com
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
TABLE 1: Overview of findings per research question (first author and year of publication of the reporting study), Continued
RQ Investigated association Positive association Negative association No association
Identified regulation –
safety Leung, 2012a; Toode, 2015 Toode, 2015
Motivation – quality Khatri, 2007; Hudelson, 2008a
Motivation – accessibility Mason, 2013
Motivation – safety Khatri, 2007
Introjected regulation –
safety Toode, 2015; Toode, 2015
External regulation –
patient centeredness Schoenfeld, 2016a Kosmala-Anderson,
2010
External regulation – safety Leung, 2012a Toode, 2015; Toode, 2015
Behavioral intention –
equitability Natan, 2009
Amotivation – quality Redfern, 1999a
2 Work engagement – core task behavior
Gordon, 2015a; Gordon, 2015a; Rodwell, 2017a; Spence Laschinger, 2009a; Spence Laschinger, 2009a
Autonomous motivation –
guideline use
Neo, 2013a; van de Steeg, 2014a
Affective commitment – core task behavior
Huang, 2012a Somers, 2000b
Organizational commitment – core task behavior
Chu, 2011a; Hsu, 2011a Johnson, 2011a
Vandenberghe, 2004a,b
Goal internalization –
core task behavior Kang, 2012a,b
Importance –
compliance Simons, 2014b Simons, 2014b
Motivation –
guideline use Lyles, 2014; Lyles, 2014; Smith, 2005
Motivation –
providing quality care
Hudelson, 2008a
Commitment – guideline use
Tapper, 2014b
Supervisor commitment – core task behavior
Vandenberghe, 2004a,b
(continues)
Motivation, Behavior, and Quality: Review www.hcmrjournal.com 161
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
TABLE 1: Overview of findings per research question (first author and year of publication of the reporting study), Continued
RQ Investigated association Positive association Negative association No association
Work group commitment – core task behavior
Vandenberghe, 2004a,b
Normative commitment – core task behavior
Huang, 2012a
Continuance commitment – core task behavior
Huang, 2012a Somers, 2000b
Controlled motivation –
protocol use Neo, 2013a; van de Steeg, 2014a
Behavioral intention –
compliance O’Boyle, 2001 Maue, 2004; Maue,
2004b; O’Boyle, 2001b
3 Intrinsic motivation – OCB Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013ba; Battistelli, 2013ba; Pohl, 2012a; Pohl, 2012a
Work engagement – extra role behavior or proactive behavior
Gordon, 2015a; Gordon, 2015a; Salanova, 2011a,b; Warshawsky, 2012a
Work engagement – OCB Rodwell, 2017a; Rodwell, 2017a
Work engagement – voicing
Wong, 2010a
Psychological empowerment – empowered behavior
Montani, 2015a; Purdy, 2010a
Psychological empowerment – proactivity
Harwood, 2007a; Kuokkanen, 2001a
Ownership – quality improvement
Harvey, 1996
Autonomous motivation –
proactivity Redfern, 1996a; Snell, 2011 Van de Wiel, 2013a
Autonomous motivation – OCB Galletta, 2012a; Galletta, 2012a
Autonomous motivation –
voicing Attree, 2007a; Brubacher, 2011; Schwappach, 2014a; Sur, 2016
Flynn-O’Brien, 2015
(continues)
162 Health Care Manage Rev • April-June 2022 • Volume 47 • Number 2 www.hcmrjournal.com
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
TABLE 1: Overview of findings per research question (first author and year of publication of the reporting study), Continued
RQ Investigated association Positive association Negative association No association
Affective commitment – OCB Battistelli, 2013ba; Battistelli, 2013ba; Bolon, 1997b; Bolon, 1997b; Boselie, 2010a; Chênevert, 2015a; Galletta, 2012a; Galletta, 2012a; Huang, 2012a; Vogus, 2016a,b; Xerri, 2013a; Xerri, 2013a
Huang, 2012a
Affective commitment – innovative behavior
Xerri, 2013a
Organizational commitment – extra role behavior or proactive behavior
Gregersen, 1993a,b; Hsu, 2011a
Johnson, 2011a
Organizational commitment – OCB
Carson, 1998a; Chu, 2011a; Cohen, 1999; Lee, 2001a; Lee, 2001a; Lin, 2015
Chu, 2005; Irvine, 2000a; Irvine, 2000a; Irvine, 2000a; Irvine, 2000a
Organizational commitment – quality improvement
Irvine, 2000a; Irvine, 2000a; Irvine, 2000a; Irvine, 2000a
Organizational identification – OCB
Bellou, 2006
Importance – quality improvement
Lindgren, 2013a
Goal internalization –
extra role behavior Kang, 2012a,b
Identified regulation –
OCB Battistelli, 2013ba Battistelli, 2013ba
Job involvement – OCB Cohen, 1999 Chu, 2005
Work involvement – OCB Cohen, 1999
Patient commitment – extra role behavior
Williams, 2007a Gregersen, 1993a,b
Career/occupational commitment – OCB
Carson, 1998a; Lee, 2001a Cohen, 1999 Lee, 2001a
Work group commitment – OCB
Gregersen, 1993a,b Cohen, 1999
Supervisor commitment – extra role behavior
Gregersen, 1993a,b
Management commitment – extra role behavior
Gregersen, 1993a,b
Introjected regulation –
OCB Battistelli, 2013ba Battistelli, 2013ba
(continues)
Motivation, Behavior, and Quality: Review www.hcmrjournal.com 163
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
TABLE 1: Overview of findings per research question (first author and year of publication of the reporting study), Continued
RQ Investigated association Positive association Negative association No association
Normative commitment – OCB
Battistelli, 2013ba; Battistelli, 2013ba; Bolon, 1997b; Bolon, 1997b; Huang, 2012a; Huang, 2012a
Rewards – proactivity Plost, 2007; Snell, 2011
External regulation – OCB Battistelli, 2013ba Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013aa; Battistelli, 2013ba; Boselie, 2010a
Continuance commitment – OCB
Battistelli, 2013ba; Battistelli, 2013ba; Bolon, 1997b; Bolon, 1997b; Galletta, 2012a; Galletta, 2012a; Huang, 2012a; Huang, 2012a
Controlled motivation –
voicing Attree, 2007a; Brubacher, 2011; Schwappach, 2014a
Attree, 2007a; Brubacher, 2011; Flynn-O’Brien, 2015; Schwappach, 2014a; Sur, 2016
Amotivation – voicing Flynn-O’Brien, 2015; Brubacher, 2011; Sur, 2016
4 Proactivity – quality Johnson, 2011a; Redfern, 1999a,b
Proactivity – effectiveness Campbell, 2008b
Proactivity – safety Agnew, 2014a,b; Dearmon, 2013b; Redfern, 1999a
Dearmon, 2013b Agnew, 2014a,b
OCB – quality D’Amato, 2008
OCB – safety Vogus, 2016a,b; Vogus, 2016a,b
Quality improvement – effectiveness
Ceballos, 2013e; Ogrinc, 2014a; Zimmerman, 2013
Zimmerman, 2013 Ceballos, 2013b; Zimmerman, 2013
Quality improvement – safety
Ceballos, 2013b; Ogrinc, 2014a
Ceballos, 2013b
Empowered behavior – quality
Purdy, 2010a
Voicing – quality Wong, 2010a
Note. Qualitative evidence is depicted in italics. RQ = research question; OCB = organizational citizenship behavior. aHigh-quality study. bExternally assessed outcome.
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
patient-centered care results from a balance between au- tonomous reasons (values) and controlled reasons (their own agenda based on external factors such as resources and fear of uncertainty).
When merely considering the high-quality studies, there was a positive association between autonomous motivation
164 Health Care Manage Rev • April-June 2022 • Volume 47 • Number
and perceived quality and safety. Patient-centeredness was stimulated by a balance of autonomous and controlled motiva- tion. The studies focusing on effectiveness, equitability, and ef- ficiency perceptions and externally assessed quality were either of low quality or reported no effect. Therefore, the effect of mo- tivation on these outcomes remains uncertain.
2 www.hcmrjournal.com
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
Motivation and Core Task Behavior Of the 19 studies that reported on the second research ques- tion, quantitative evidence was presented in 15 studies, and four studies presented qualitative evidence. The quantitative findings were that autonomous motivation, most often investi- gated in terms of work engagement and organizational commit- ment, positively influenced self-reported core task behavior and guideline adherence. Mixed (positive and no) results were found for the relationship between autonomous motivation and externally assessed core task behavior. One study reported that the relationship between autonomous motivation and supervisor-assessed core task behavior was mediated by com- mitment to the supervisor. Whereas normative commitment had a positive association with core task behavior, continuance commitment had a negative association with core task behav- ior. Mixed effects were reported for behavioral intention and an otherwise unspecified sense of motivation in relationship to self-reported guideline adherence. Behavioral intention did not predict observed guideline adherence.
The qualitative evidence also supported positive associations between autonomous motivation and core task behaviors. Core task behavior was reported to result from a balance between autonomous and controlled motivation, in which controlled mo- tivation contributed to as well as inhibited this type of behavior.
When merely considering the high-quality studies, auton- omous motivation was positively associated with core task behavior. Moderately controlled motivation contributed to core task behavior, but motivation at the most controlled end of the continuum did not to contribute to and even inhibited core task behavior. As the studies on behavioral in- tention were of low quality, its effect remains unclear.
Motivation and Proactive Behavior The third research question was investigated in 43 studies, of which 32 presented quantitative findings and 11 presented qualitative findings. The quantitative evidence generally showed a positive relationship between autonomous motivation and proactive behavior, but findings were mixed for identified regula- tion, involvement, and organizational commitment. Controlled motivation had no or a negative association with self-reported proactive behavior. Furthermore, controlledmotivation, commit- ment to patients, and goal internalization did not affect externally assessed proactive behavior. For voicing behavior, it was found that, whereas autonomous motivation stimulated voicing be- havior, this behavior was discouraged by extrinsic factors (e.g., colleagues’ approval and the fear of failure).
The qualitative findings supported the positive association between autonomous motivation and proactive behavior. Nevertheless, it was observed that even if health care profes- sionals experience a sense of ownership or find quality im- provement important, this autonomous motivation may exist without actual engagement in proactive behavior. Sim- ilar to the quantitative findings, autonomous and controlled reasons simultaneously stimulated proactive behavior, quality improvements, and voicing behavior. However, for voicing behavior, controlled motivation held the potential to over- rule autonomous motivation to speak up, thereby preventing this type of behavior.
Motivation, Behavior, and Quality: Review
Overall, autonomous motivation was positively associ- ated with proactive behaviors. The association between controlled motivation and proactive behavior was depen- dent on the type of proactive behavior; whereas controlled motivation, combined with autonomous motivation, stimu- lated quality improvements and possibly also proactivity, controlled motivation negatively affected voicing behavior. When merely considering the high-quality studies, the re- sults do not change.
Proactive Behavior and Quality of Care Of the 12 studies reporting on the fourth research question, nine reported on quantitative findings and three reported on qualitative findings. The quantitative results showed that proactive behavior positively influenced perceived quality and had mixed effects on externally assessed quality and safety. Proactive behavior even had a negative effect on safety when safety was operationalized in terms of a low number of reported incidents in the hospital system. Furthermore, al- though proactivity among nurses stimulated nurse compliance to screening, it had no influence on the actual effectiveness of care delivered by physicians. Regarding quality improvement projects, positive effects were found on care effectiveness and safety, except when the patients were vulnerable. Voicing be- havior was not associated with quality perceptions.
The qualitative evidence resembled these findings. Patients as well as nurses perceive nurses’ proactivity as an indicator of high-quality care, and nurse-reported (but not externally assessed) proactivity was indeed associated with externally assessed safety outcomes. Furthermore, interventions to stimulate proactivity or quality improvements had generally positive effects on externally assessed safety and effectiveness, but when patients were vulnerable, quality improvements had less or no effect.
When merely considering the high-quality studies, there was a positive association between self-reported proactive be- havior and self-reported quality. Proactive behavior had a positive association with externally assessed safety in terms of the absence of harm to patients, but it had no or even a negative association with externally assessed safety when this was operationalized as the number of incident reports. The studies reporting on externally assessed proactive behavior, voicing behavior, or evaluations of interventions were of low quality, which limits their reliability.
Discussion This review highlights the importance of autonomous motiva- tion for health care professionals’ behaviors and the quality of care.We show that autonomous motivation is directly and pos- itively associated with quality, safety, and patient-centeredness, whereas controlled motivation and amotivation are negatively associated with quality.
In addition, the findings of this review provide nuanced insights on the role of controlled motivation and incentives. Moderately controlled motivation is positively associated with core task performance, as observed in the organizational literature. In contrast with findings from the field of organiza- tional studies, which support a positive effect of external reg- ulation on performance (Cerasoli et al., 2014), our findings
www.hcmrjournal.com 165
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
show that motivation at the most controlled end of the con- tinuum is not or negatively associated with health care profes- sionals’ core task behaviors. This discrepancy might be due to differences between work motivation of health care profes- sionals versus of employees from other types of organizations. In a study comparing the motivation of for-profit and not-for- profit employees (with the latter group including hospital em- ployees as their organization has a social rather than a profit mission), not-for-profit employees had lower external regula- tions than employees working in organizations driven by monetary goals (De Cooman, De Gieter, Pepermans, & Jegers, 2011). Furthermore, studies among medical students indicate that they choose their profession out of intrinsic and identified motivation rather than extrinsic motivation (Berenson & Rice, 2015), and they maintain this high level of intrinsic motivation throughout their career (Berenson & Rice, 2015; Scheepers et al., 2015). Because of this high level of intrinsic motivation and low level of external regulation, health care professionals might not be very susceptible for ex- trinsic motivators. This would also provide an explanation for the finding that providing incentives does not stimulate pro- active behaviors and quality improvement, unless this is com- bined with autonomous reasons to act. These observations challenge the emphasis on incentivizing (e.g., financial in- centives) and penalizing (e.g., public reporting) as a means to extrinsically motivate health care professionals to improve quality and potentially explain why these methods have not reached their anticipated success (Berenson & Rice, 2015; Flodgren et al., 2011; Franco et al., 2002).
Furthermore, our review sheds further light on the role of proactive behavior in the health care setting. Our findings show that proactive behavior generally contributes to effec- tiveness, but only when the treatment is under the direct con- trol of the proactive health care professional. In addition, proactive behavior contributes to safety, but not if safety is operationalized as the number of reported incidents. We ar- gue that the number of reported incidents is probably not a valid measure of patient safety, which is confirmed by our finding that autonomous reasons contribute to voicing, but that this motivation can be overruled by controlled reasons to act, such as social reprimands. We state that the number of reported incidents reflects the safety culture or the learning potential of an organization; if there is a supportive safety cul- ture, health care workers are more willing to act proactively and voice incidents (Ancarani, Di Mauro, & Giammanco, 2017). This could also explain the observed positive relation- ship between proactive behavior and reported incidents. Considering this point, we conclude that proactive behavior contributes to the quality and safety of care.
Practice Implications The key policy priority to improve quality of care is to stimu- late health care professionals’ autonomous work motivation. Although our review confirms that controlled motivation has its positive sides (Cerasoli et al., 2014), it negatively af- fects quality perceptions and voicing behavior. Therefore, current efforts to extrinsically motivate health care profes- sionals to improve specific quality outcomes by incentivizing
166 Health Care Manage Rev • April-June 2022 • Volume 47 • Number
or penalizing need to be revised. It is recommended that these incentive-based interventions are complemented with as- pects to simultaneously stimulate autonomous motivation, such as alignment with health care professionals’ drives and values, autonomy, supportive supervision, appreciation, re- spect and good interpersonal relationships, and growth op- portunities (Berenson & Rice, 2015; Keyko et al., 2016).
Furthermore, as we observed that motivation based on normative considerations predicts core task behavior well, we suggest that, to increase compliance for specific core task behaviors, such as hand hygiene, one might want to appeal on health care professionals’ sense of professionalism; the in- ternalized professional norms and values to act in the interest of the patient. Health care leaders can set the norm by engag- ing in exemplary behaviors (Ancarani et al., 2017; Berenson & Rice, 2015; Franco et al., 2002).
The next recommendation is to facilitate health care pro- fessionals’ proactive behaviors. In uncertain contexts, systems awareness, organizational learning, and continuous quality improvement are essential, and acting proactively is “part of the job” (Griffin et al., as cited in Gagné, 2014; Hollnagel et al., 2015). It is increasingly recognized that establishing quality and safety is no longer merely “avoiding that some- thing goes wrong,” rather, it is “ensuring that as many things as possible go right” (Hollnagel et al., 2015) by acting proac- tively and raising concerns. In line with this thinking, we state that, to unleash the learning potential of health care or- ganizations and to improve the quality of care, proactive be- havior needs to be recognized as a fundamental part of health care professionals’ job requirements and needs to be appreciated and facilitated accordingly, for example, by allo- cating resources (e.g., time, equipment, training) for quality improvements, normalizing voicing behavior, and establish- ing a shame- and blame-free environment for raising con- cerns, learning, and improvement (Ancarani et al., 2017).
This review focused on the hospital setting, and our rec- ommendations might apply beyond this setting as well. Care provision takes place within the clinical microsystem (the team of health care professionals caring for a patient; Fulop & Ramsay, 2019), and as these can be found in several set- tings such as primary care clinics, mental health care, and chronic care, we assume that our findings and recommenda- tions translate to those settings as well. However, the extent to which our research translates to other health care systems outside high-income countries may be limited, as Fritzen (2007) stated that in low- and middle-income countries, there is “often a disjunction between formal responsibilities and the requisite resources to meet minimum specific standards.” In other words, the availability of resources, which varies per sys- tem, affects the extent to which health care professionals are able to act upon their motivation to provide and improve care.
It is important to note that achieving high-quality provi- sion in hospitals is complex and influenced by intertwined factors from the organizational context and the broader envi- ronmental context. These factors include organizational characteristics (e.g., size, scale, structure, information systems, leadership, and culture) and broader environmental character- istics such as governance, regulation, and finance of the health
2 www.hcmrjournal.com
D ow
nloaded from http://journals.lw
w .com
/hcm rjournal by B
hD M
f5eP H
K av1zE
oum 1tQ
fN 4a+
kJLhE Z
gbsIH o4X
M i0hC
yw C
X 1A
W nY
Q p/IlQ
rH D
3i3D 0O
dR yi7T
vS F
l4C f3V
C 1y0abggQ
Z X
dtw nfK
Z B
Y tw
s= on 11/09/2023
care system (Fulop & Ramsay, 2019). These factors should be aligned to provide health care workers with the resources, in- cluding autonomousmotivation, for high-quality care delivery.
Limitations and Future Research The results of this review need be interpreted in consideration of its limitations. First, the alignment of the motivational con- cepts along the self-determination theory continuum may re- flect an overly simplistic view of these concepts, and the list of aligned concepts might not have been exhaustive. The gen- eralizability of this approachmay therefore be limited when in- vestigating other, but related, concepts (e.g., altruism). In addition, some studies may have been overlooked due to pub- lication bias, not incorporating gray literature and because the search string was not exhaustive. Furthermore, we observed a suboptimal interrater agreement regarding the inclusion of the studies, which we resolved by performing the screening of all abstracts and full-text records by two independent re- viewers. Future researchers might prevent this issue by stating the inclusion and exclusion criteria more explicitly, especially for ambiguously described studies (e.g., include, unless it is completely clear that an exclusion criterion applies). In addi- tion, the extensive QA, which included questions concerning the risk of bias, may not have completely eliminated the po- tential influence of bias. Regarding all research questions, it is noted that most studies use self-reported measures of behav- ior or quality, and therefore, the evidence for the effect of mo- tivation on externally assessed behavior and quality is limited. Finally, most studies based their conclusions on correlations or regression analyses. In the absence of sufficient longitudinal or (quasi-)experimental studies, we cannot unambiguously deter- mine the causality of the relationships we studied.
These limitations should be addressed in future work, as well as the following recommendations. This review shows that autonomous and controlled motivation might influence behavior simultaneously. Building on studies about motiva- tional or commitment profiles (e.g., Gagné, 2014), future (quasi-)experimental studies might aim at getting a better un- derstanding of the “right” balance between extrinsic rewards and autonomous motivation for the provision of high- quality care. To conclude, it is strongly recommended that fu- ture studies incorporate objective and valid measures to study health care professionals’motivation, behaviors, and the (ex- ternally assessed) quality of care dimensions.
Conclusion To improve quality of care, policy makers and managers need to support health care professionals’ autonomously motivation and facilitate them to act proactively and “go the extra mile” for their patients. Combining autonomous and controlled mo- tivation holds the potential to boost quality of care, but more insight is needed into how to balance these types of motivation in such a way that it does not thwart voicing behaviors.
Acknowledgments Wewould like to express our gratitude to our student assis- tants Rick Overwijk and Marcel Schmidt for their help in
Motivation, Behavior, and Quality: Review
the screening phases of this review. We are thankful to Helena VonVille for providing us with the Excel work- books and advise. We are grateful to the University Med- ical Center Groningen and the University of Groningen as the submitted work was undertaken as part of a PhD program funded by these two institutions.
References Ajzen, I. (1991). The theory of planned behavior.Organizational Behavior and
Human Decision Processes, 50(2), 179–211. Ancarani, A., Di Mauro, C., & Giammanco, M. (2017). Hospital safety cli-
mate and safety behavior: A social exchange perspective. Health Care Management Review, 42(4), 341–351.
Berenson, R. A., & Rice, T. (2015). Beyond measurement and reward: Methods of motivating quality improvement and accountability. Health Services Research, 50, 2155–2186.
Cerasoli, C. P., Nicklin, J. M., & Ford,M. T. (2014). Intrinsicmotivation and extrinsic incentives jointly predict performance: A 40-year meta-analysis. Psychological Bulletin, 140(4), 980–1008. 10.1037/a0035661
De Cooman, R., De Gieter, S., Pepermans, R., & Jegers, M. (2011). A cross-sector comparison of motivation-related concepts in for-profit and not-for-profit service organizations. Nonprofit and Voluntary Sector Quar- terly, 40(2), 296–317.
Flodgren, G., Eccles, M. P., Shepperd, S., Scott, A., Parmelli, E., & Beyer, F. R. (2011). An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. The Cochrane Database of Systematic Reviews, 7. 10.1002/14651858.CD009255
Franco, L. M., Bennett, S., & Kanfer, R. (2002). Health sector reform and public sector health worker motivation: A conceptual framework. Social Science & Medicine, 54(8), 1255–1266.
Fritzen, S. A. (2007). Strategic management of the health workforce in devel- oping countries:What have we learned?Human Resources for Health, 5(1), 4.
Fulop, N. J., & Ramsay, A. I. G. (2019). How organisations contribute to im- proving the quality of healthcare. BMJ, 365, l1773.
Gagné, M. (Ed.) (2014). The Oxford handbook of work engagement, motivation, and self-determination theory. New York, NY: Oxford University Press.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medi- cine: A movement in crisis? BMJ, 348, g3725.
Harden, A. (2010). Mixed-methods systematic reviews: Integrating quantita- tive and qualitative findings. Focus, 2010(25), 1–8.
Hollnagel, E.,Wears, R. L., & Braithwaite, J. (2015). From safety-I to safety-II: A white paper. The resilient health care net. Published simultaneously by the University of Southern Denmark, University of Florida, and Macquarie University.
Keyko, K., Cummings, G. G., Yonge, O., & Wong, C. A. (2016). Work en- gagement in professional nursing practice: A systematic review. Interna- tional Journal of Nursing Studies, 61, 142–164.
Kim, W., Kolb, J. A., & Kim, T. (2013). The relationship between work engagement and performance: A review of empirical literature and a proposed research agenda. Human Resource Development Review, 12(3), 248–276.
Kmet, L. M., Cook, L. S., & Lee, R. C. (2004). Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmon- ton, Canada: Alberta Heritage Foundation for Medical Research.
Scheepers, R. A., Boerebach, B. C., Arah, O. A., Heineman, M. J., & Lombarts, K. M. (2015). A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. International Journal of Behavioral Medicine, 22(6), 683–698.
The World Bank Group. (2016). World bank list of economies (July 2016). Retrieved from https://siteresources.worldbank.org
Van Dyne, L., & Pierce, J. (2004). Psychological ownership and feelings of possession: Three field studies predicting employee attitudes and organiza- tional citizenship behavior. Journal of Organizational Behavior, 25(4), 439–459. 10.1002/job.249
World Health Organization. (2006).Quality of care: A process for making stra- tegic choices in health systems. Retrieved from http://www.who.int
www.hcmrjournal.com 167