follow up discussion

Understanding and motivating health care employees: integrating Maslow's hierarchy of needs, training and technology

SUZANNE G. BENSON P h D and STEPHEN P. DUNDIS J D , P h D

Assistant Professor, Human Resource Development Program, Northeastern Illinois University, Chicago, IL, USA

Challenges in the health care sector

The health and human service industry is undergoing

one of the most massive transformations of any industry

in our history (Fitz-Enz 1998), due, in part, to mergers,

reorganizations, cost containment, a changing work-

force and technological changes that are doubling every

3 years. In addition to the furious evolution of medical

technology, provider demands are increasing, in part,

because people are living longer (Lozada 1995).

According to the US Bureau of Labor Statistics (1999),

the population over 95 is growing four times as fast as

Correspondence

Suzanne G. Benson

Human Resource Development

Program

Northeastern Illinois University

5500 North St Louis Avenue

Chicago, IL 60625

USA

E-mail: [email protected]

B E N S O N S . G . & D U N D I S S . P . (2003) Journal of Nursing Management 11, 315–320

Understanding and motivating health care employees: integrating Maslow's hierarchy of needs, training and technology

Aim This paper applies Maslow’s Hierarchy of Needs Model to the challenges of understanding and motivating employees in a rapidly changing health care industry. Background The perspective that Maslow’s Model brings is an essential element

that should be considered as the health care arena is faced with reorganization,

re-engineering, mergers, acquisitions, increases in learning demands, and the esca-

lating role of technology in training.

Evaluation This paper offers a new perspective related to how Maslow’s Model, as

used in business/organizational settings, can be directly related to current workforce

concerns: the need for security and freedom from stress, social belongingness, self-

esteem, self-actualization, altered work/social environments, and new opportunities

for learning and self-definition.

Key issues Changes in health care will continue at an accelerated pace and with

these changes will come the need for more and more training. The use of technology

in training has heightened access, faster distribution, innovation and increased

collaboration. However, with this technology come attendant challenges including

keeping up with the technology, the increased pace of training, depersonalization,

and fear of the unknown. The Maslow model provides a means for understanding

these challenges in terms of universal individual needs.

Conclusion How does one motivate employees in the face of increased demands,

particularly when they are being asked to meet these demands with fewer resources?

The answer is, in large part, to make the employee feel secure, needed, and

appreciated. This is not at all easy, but if leaders take into consideration the needs of

the individual, the new technology that provides challenges and opportunities for

meeting those needs, and provides the training to meet both sets of needs, enhanced

employee motivation and commitment is possible.

Keywords: adult learning, human resource development, technology, training

Accepted for publication: 13 February 2003

Journal of Nursing Management, 2003, 11, 315–320

ª 2003 Blackwell Publishing Ltd 315

the total population, and national health care expen-

ditures are 50% higher than the defense budget;

amounting to more than 940 billion dollars yearly. It is

not surprising therefore that the US Department of

Labor Occupational Outlook Handbook found that

there are numerous health care related occupations that

will grow faster than the overall average workforce

through the year 2005. This has become an eminent

concern to health care providers as current deficiencies

are placing an ever increasing burden correlated to the

shortages found in a variety of related occupational

areas.

As new health care reforms are implemented and

standards are revised, the demand for continuous

quality improvement and management in these settings

will also continue to rise. Kover and Neuhauser (1988)

suggest that given all the changes the health care

industry will face, adapting the organization will be the

greatest challenge administrators face. White (1998)

posits that this sector will find an increased need for

health and human service management and training,

in part because of the increased need for: strategic

planning and efficiency, the transformation to a market-

oriented, consumer provider paradigm, and an elimin-

ation of the traditional hierarchy. Further, Shortell and

Kaluzny (1995) suggest that change in the health sector

will be a dominant theme into the next century. This

will provide both opportunities and challenges for

training to assist in the successful transition to effective

organizations. It is not surprising therefore that the

1999 American Society for Training Development

(ASTD) State of the Industry Report (Basi & Van Buren

1999) found that of those responding, the area training

the largest number of employees was found in health

care (88%).

With the challenges facing this sector, including

advances in technology, the metamorphosis occurring

in the demographic and diversity of the workforce,

the restructuring, re-engineering, downsizing, and

current events facing those in the health and human

service sector, understanding the needs of the worker

becomes more essential than ever to promote a heal-

thy work environment. Understanding what motivates

the individual as well as how the manager can suc-

cessfully motivate the staff and the leaders motivate

the entire organization is a question of increasing

concern.

Abraham Maslow's model

One way to understand, and motivate, the individual

is to revisit Abraham Maslow’s Hierarchy of Needs

(Maslow 1954), which has and continues to be used as

a means to assist in understanding human behaviour.

Maslow’s model has been studied in various disci-

plines: in business it is approached as a model for

understanding motivation; in the social sciences

including adult learning, psychology, sociology and

education, it is used as a model for understanding the

needs of individuals. Regardless of the discipline, it has

been and continues to be used for understanding what

the driving forces are, or what is important to indi-

viduals.

Although there has been considerable debate whether

Maslow created a model or simply a means to explain

motivation, for clarity, this paper will address it as a

model. Maslow created a visualization of his hypothesis

in the shape of a pyramid which is divided into five

levels. At the bottom of the pyramid is the physiological

level which includes food, water and shelter, the most

basic needs for human survival. The premise is that

unless an individual’s basic needs have been met, higher

levels in the pyramid are of no relevance, as survival is

the most basic human component.

When the basic survival needs have been met, the

individual moves to the next level and seeks safety,

including freedom from anxiety and stress. Stress,

unfortunately, appears to be a constant in our culture.

Ashkanasy and Hartel (2000), practising consultants in

workplace health, suggest that the work life of the

modern employee is more pressured today than at any

other time in the history of work. Therefore, although

anxiety and stress may be a constant, we need to look at

these elements on an individual basis and on a con-

tinuum from moderate to extreme.

Once the stress level has been moderated, or is

acceptable, for the individual, and basic safety con-

ditions, as defined by the individual, have been met,

he/she would then look to the third stage which is

identified as the social level. This area includes the

need for belongingness, friendship and love. It is

important to note that all levels have a varying ele-

ment of depth for the individual; what is adequate or

necessary for one may be inadequate for another.

Thus, although we all seek security in relationships,

the need for belonging will be greater for one person

than it will be for another because we are dealing

with individual needs.

Having obtained relationship/belongingness security,

it is then possible to look to the fourth level, self-esteem.

In this arena the individual seeks to feel competent,

confident and self-assured. Finally, the individual, hav-

ing met the needs of the former four levels is able to

pursue self-actualization – or to ‘be all that one can be’.

S.G. Benson and S.P. Dundis

316 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 315–320

Malsow's model in the business/ organizational environment

Maslow’s model is a constructive tool in understanding

individual human behaviour; its use in the business/

organizational setting provides a means to understand

and affect employee motivation. In the work setting

Maslow’s model has the same five levels, but the defi-

nitions were modified in the following manner by

Maslow himself and authors of numerous management

books and texts. At the base, the first basic level that

must be satisfied is that of wages. Maslow posited that

if individuals are, in their minds, fairly paid, they will

not spend an inordinate amount of time thinking about

their salaries (Maslow 2000). Conversely, if an indi-

vidual does not believe that he/she is being paid a fair

wage, too much time will be spent contemplating this

perceived inequity and other work concerns will not be

given the attention that might be required. There is a

correlation between the traditional model and that

found in the work environment. Basic survival needs

must be met with wages which in turn provide shelter,

food, water, heat, clothing, etc.

With adequate wages, the individual seeks safety on

the job. This includes not only physical, but mental

safety. A secure working environment can also mean

the decreased anxiety produced by adequate benefits,

union contracts, etc. Training occupies an important

position at this level because the worker consciously

and subconsciously relates training to safety. For

instance, a person trained on a piece of machinery is a

safer worker than one that has not had the training and

has been required to learn by trial and error. However,

the worker also associates the willingness of the com-

pany to spend resources, time and money, on his/her

training as an assurance that he/she is of value to the

company. Maslow (2000) also suggests that… ‘it is a rare individual who is completely secure in his work

environment’ but training helps (p. 2).

Individuals then move to the third level seeking social

belongingness in the workplace. Anyone having

experienced the ordeal of feeling socially uncomfortable

in a work setting can understand the importance of

workplace collegiality. We seek pleasant working rela-

tionships with co-workers, peers, and others in the

hierarchy; we seek to find our place in formal and

informal work groups. The social needs ‘wax and wane

on the strength of our personal relationships and our

participation with others in the organization’ (Maslow

2000, p. 2). Unfortunately, in the highly pressured

environments employees often find themselves working

in, making others socially comfortable or ‘fitting in,’ is

given less and less consideration. Training provides the

individual with additional opportunities to meet people

in the place of employment, to discover others with the

same interests or job responsibilities, and to establish

new lines of communication. Although much consid-

eration is given to the technical aspects of training, the

social element cannot and should not be underestimated

for establishing firmer workplace bonds. Thus, although

Maslow specifically related training to only two of his

levels – security and self-actualization, we posit that

training, especially in the increasingly technological

realm that it occupies, relates specifically to two other

levels as well – social belongingness and self-esteem.

Self-esteem in the organization is generally based on

the individual’s successful performance appraisals,

incentives, rewards received and recognitions obtained,

all which enhance self-confidence. As the individual

obtains training, it presents an opportunity to feel and

actually be more productive and confident in the work

environment. In turn, as the individual’s confidence level

grows there is greater opportunity to obtain rewards,

recognition and positive performance appraisals.

Finally, training allows the individual to move

toward self-actualization; to develop one’s potential, to

learn new things, to take risks, and to feel even more

confident in what one does. As the individual learns,

and grows in the work environment Maslow suggests

that, ‘Duty becomes pleasure and pleasure is merged

with duty’ (2000, p. 25).

Technology, training and the hierarchy of needs

Technology provides new ways to think about, learn

about, and complete tasks which provides the organ-

ization with new opportunities. These opportunities,

however, also bring with them new challenges. First, we

must remember that individuals tend to resist change.

This resistance can be attributed to a number of factors

including a fear for job security, loss of power/prestige,

and changes in relationships. Also, people fail to relate

change to their perceived personal needs, or on a larger

scale, to those of the organization. In the constantly

shifting landscape that is technology, we have to be

cognizant of these fears and failures. Maslow’s model

can, we believe, give us some much needed perspective.

Security

The Training Industry Report 1998 (1998, October)

found that 20% of all training was being provided by

computer. One year later, more than 50% of respondents

Understanding and motivating health care employees

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 315–320 317

to the same survey indicated that they used computer-

based training delivered via CD-ROM, 33% use the

Web, and 25% used the company internet. In addi-

tion, it is anticipated that by the year 2006, as much as

60% of all training will be technologically based. This

does not mean that new technology has been auto-

matically embraced by individuals. In fact, it has

affected the individual’s basic security needs (or

Maslow’s level two) in several ways. First, there is a

basic security concern that new technology will reduce

the number of employees required to complete job

tasks, or that it will require knowledge and skills that

the individual does not currently possess. In this latter

scenario there is the perception that the lack of know-

ledge or ability to learn the requisite skills will place

jobs in jeopardy.

Technology can allow for new and innovative ways

to train employees and allow, once again, freedom from

the fear associated with the technology. However, these

new and innovative training methods also require new

knowledge, including operating computers, using new

software, navigating websites, etc. Workers may feel

increased stress, particularly as the technological chan-

ges become more rapid.

Finally, while technology has allowed for faster dis-

tribution of training and communication to almost any

locale, this too has created an enhanced stressful scen-

ario. People are expected to keep up with the increasing

pace of training or, in some cases, just the constant

flood of e-mails. This constant communication often

requires workers to respond even if it requires com-

pleting a portion of it from their personal comput-

ers at home during personal time. The supposedly

more peaceful home environment is being increasingly

breached.

Social belongingness

The technology associated with new ways to work

and learn also provides for advantages and concerns

in the social needs arena. ‘With the advent of e-mail

and the internet, organizations are uncovering the

benefits and challenges of reducing face-to-face com-

munication, and expanding the boundaries of work

spaces and teams. The ability to reduce in-person

teamwork via electronic and web-based techniques

has created a new aspect of the team concept – virtual

teams’ (Hagan 1999, p. 2). This virtual teaming

provides numerous benefits to the company including

the ability to construct teams without concern for

where the members are geographically or organiza-

tionally located.

However, this new form of communication also

brings with it new problems. People often find a lack of

what Murphy and Collins (1997) refer to as ‘social

presence’ in online communications – those intangible

qualities present when people are face-to-face. And

while the internet has increased the possibility of com-

munication, it has also increased the possibility for

misunderstanding; electronic communication eliminates

eye contact, body language, voice inflection and other

communication cues. These misunderstandings can lead

to conflict and tension, and escalate, especially when

there is no opportunity to see team members in the hall

(Gould 1999).

The opportunities to participate in new and different

work groups can certainly expand the employees’ be-

longingness bases, and grant them the opportunity to

work with and become familiar with others that would

not normally be possible. However, within the health

care arena this can bring together different professional

cultures that may clash. ‘The education and training of

health care professionals shape their identities, values,

and norms of practice in certain ways that may either

enhance or inhibit effective communication and colla-

boration…’ (Clark 1997, p. 442). They are often, ‘Protectively housed, trained and socialized in separate

schools and colleges, away from the ‘‘contaminating

influences’’ of other professions’ (Clark 1997, p. 442).

This training and socialization provides a level of be-

longingness sought by individuals, but also creates

predictable patterns in professional practice. The addi-

tion of new and varied work groups often takes the

employee out of their comfort area into a new realm.

It is also imperative that technological training not be

limited to the actual technology being used. For exam-

ple, how does one ensure that their true intent is being

relayed in a written electronic message? Certainly, in

our global environment, it is important that employees

are trained in understanding differences in communi-

cation styles, patterns, perceptions and cultures. If car-

ried out properly, this training as the opportunity to

ease tension and avoid conflict. Communication and

cultural training becomes even more imperative when

technology is being used. Finally, it is important that as

organizations embrace the concept of virtual groups,

individuals be provided with training in group dynam-

ics, not just thrust into the process.

Self-esteem

Group decision making in hospitals and by health care

providers is evolving along with new technological

methods of communicating. Shared governance in the

S.G. Benson and S.P. Dundis

318 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 315–320

health care arena emerged in the 1980s and continues

as a popular hospital-based, organizational design

using a participatory approach to management and

creating a decentralized environment (Genrich et al.

2001). The use of technology has enhanced commu-

nication and work groups and provided an even

greater method of participating in this approach; it

presumably allows more employee input into the

decision-making process. However, research has also

found that decisions made at the group level are often

changed or reversed at a higher organizational level

(George 1997). If employee decisions, ideas and con-

cerns are not attended to, involvement disappears. It is

not simply the decisions that are overlooked, it is the

employee that took part in them, and they often feel

misunderstood and unappreciated – their self-esteem is

diminished. As The Maslow Business Reader asserts,

individuals avoid: being manipulated, misunderstood,

unappreciated, not taken seriously, and not respected

(to name a few).

Another self-esteem issue related to technology is the

concern that individuals will become numbers in the

organization; individuals not known by name, or

interacted with personally, but by electronic commu-

nication. Maslow made a prophetic statement more

than 30 years ago, when technology was not yet

advanced. ‘How can any human being help but be

insulted by being treated as an interchangeable part, as

simply a cog in a machine, as no more than an appur-

tenance to an assembly line?’ (2000, p. 58).

Finally, it should be remembered that, besides

affecting stress levels, the perceived failure to ‘keep up’

with technology can create self-esteem problems. People

tend to hide what they feel is their technological

ignorance from others, even when they are given the

opportunity to learn.

Self-actualization

In no other area of human need does technology make

more promises than that of self-actualization. Citing

again from The Maslow Business Reader (2000), ‘Think

of the huge acceleration in the rate of growth of facts,

knowledge, of techniques, of inventions, of advances in

technology. It seems very obvious that this requires a

change in our attitude toward the human being, and

toward his relationship with the world’ (p. 188).

Technology provides everyone, that has access to it,

unlimited means of learning, exploring, and developing;

a way to become self-actualized.

The training industry reflects this optimism with its

focus on education vs. training. The person should not

only be taught to perform certain job functions, or

trained, he/she should also be educated, or exposed to

learning that touches every interrelated part of her/his

life. The whole person should be addressed in ways that

go beyond pure job performance, but instead addres-

ses life performance. This is evidenced by the steady

increase in the availability of soft skills training, and a

focus on the active learner; one who is empowered to

choose the learning they themselves want and feel they

need.

However, self-actualization offers its own set of

challenges to both the organization and the individual.

‘Life performance’ is a complex and ill-defined issue

with consequences that can often be nebulous. For the

organization, addressing this issue with little clear or

established direction could represent a huge expenditure

of expertise and resources with no clear effect – at least

no clear effect on the organization’s bottom line survi-

val. Additionally, while technology may offer much

more access to education on many levels, the individual

must already be self-directed enough to take advantage

of it in a meaningful way. Individuals may need help in

overcoming a long tradition of passive learning that

they have become accustomed to.

Conclusion

How does one motivate employees when so many are

being asked to do more with less? The answer is, in a

large part, to make the employee feel secure, needed and

appreciated. If leaders, those that have the ability to

influence the lives of workers, take into consideration

the needs of the individual, the new technology that

provides challenges and opportunities for meeting those

needs, and provides the training to meet both sets of

needs, enhanced employee motivation and commitment

is possible. The Maslow model presents a means for

understanding the needs of the individual and the

worker; ever present and growing technology allows for

new ways to meet these needs; and training makes the

worker more secure, can enhance feelings of belong-

ingness and self-esteem, and provides the opportunity

for self-actualization.

References

Ashkanasy N.M. & Hartel C.E.J. (eds) (2000) Emotions in the

Workplace: Research, Theory and Practice. Quorum Books,

Westport, Conn.

Basi L.J. & van Buren M.E. (1999) The 1999 ASTD state of the

industry report. Training and Development 53 (1) (suppl.),

1–27.

Understanding and motivating health care employees

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 315–320 319

Clark P.G. (1997) Values in health care professional socialization:

implications for geriatric education in interdisciplinary team-

work. Gerontologist 37 (4), 441–451.

Fitz-Enz J. (1998) Industry change ¼ internal change. HRD/OD, American Management Association International 1 (2), 5.

Genrich S.J., Banks J.C. & Bufton K. (2001) Group involvement

in decision making. The Journal of Continuing Education in

Nursing 32 (1), 20–26.

George J. (1997) Nurses’ perceived autonomy in a shared gov-

ernance setting. Journal of Shared Governance 3 (2), 17–21.

Gould D. (1999) The virtual organization (on-line), available:

http://www.seanet.com/%7Edaveg/ltv.htm

Hagan M.R. (1999) Teams expand into cyberspace. Quality

Progress 32 (6), 90–93.

Industry Report 1998 (1998, October). Training 43–76.

Kover A.R. & Neuhauser D. (1988) New Management in Human

Services. National Association of Social Workers, Silver

Springs, MD.

Lozada M. (1995) The health occupations boom. Vocational

Education Journal 70 (6), 34–37.

Maslow A.H. (1954) Motivation and Personality. Harper and

Row, New York.

Maslow A.H. (2000) The Maslow Business Reader (D.C. Ste-

phens ed.), John Wiley & Sons, New York.

Murphy K.L. & Collins M.P. (1997) Communication Con-

ventions in Instructional Electronic Chats. Available at: http://

www.firstmonday.dk/issues/issue2_11/murphy/

Shortell S.M. & Kaluzny A.D. (1995) Health Care Management:

Organization Design and Behavior. 3rd edn. Delmar Publish-

ers, Inc., Albany, NY.

US Bureau of Labor Statistics (1999) 1998–1999 Occupational

Outlook Handbook. Available at: http://www.bls.gov

White D.B. (1998) Client and practitioners perceptions of

organization development utility and effectiveness in health and

human service organizations: a national study. Organization

Development Journal 16 (1), 45–58.

S.G. Benson and S.P. Dundis

320 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 315–320