An Analysis of Employee Motivation After Metamorphose,
Conglomerated Public Health Care Systems
Chapter 1: Introduction to the Study
Introduction
Fundamental theories in public administration support mergers and acquisitions as
a mechanism to improve organizational concerns, such as quality of care, values and
beliefs, costs, and financial performance for health care organizations (Ghiasi, Zengulf,
Ozayin, Oner, & Breland, 2017). According to Sehleanu (2015), theories such the
efficiency, market power, disciplinary takeover, agency and managerial hubris theories
support the contribution of mergers and acquisitions as the link between theories in
public administration and mergers and acquisitions. For example, public administrators
may use the efficiency theory to improve cost performance. Cost performance is a
measure of the efficiency of completed work for every unit of cost spent. The use of this
theory can lead to increases in an organization’s economic efficiency through synergies
as a result of pooling together all tangible and intangible assets of the acquiring and
acquired companies.
Synergy strategies from the market power theory can be attractively used for a
merger and acquisition method by way of firms merging or acquiring other entities in
order to increase the monopoly power as a motivator for operations. According to
Sehleanu (2015), the synergies of the monopoly power gained through mergers and
acquisitions may strengthen or enhance the market power of the companies, which is
reflected in the ability of a company to set the selling price of products and/or to increase
its profit margin and benefits. Some organizations may use the disciplinary takeovers
theory as a course of action to improve performance when an organization is undervalued
due to inefficient management. When the disciplinary takeover theory is used, generally,
it means that the organization has not reached the desired performance parameters and a
management team from another company will take over the business and will replace the
managers. In doing so, managers who pursue their own agendas or are incompetent will
be removed and replaced with more competent and efficient managers.
The agency theory supports mergers and acquisitions in a way that focuses on the
relationship of shareholders and managers. The rapport between shareholders and
managers is important to organizations during mergers and acquisitions due to the
possibilities of conflicts of interest. Sehleanu (2015) claimed that conflicts of interest
bring about problems that may occur in the context of separation between ownership and
control. The managerial hubris theory is described by Sehleanu (2015) as managers who
have the “ego syndrome” (p. 543) or mangers who have a shortened vision of reality.
The ego syndrome can be difficult for managers who are replaced during a disciplinary
takeover.
Research on health care partnerships and markets conducted by several scholars—
Siegel, Erickson, Milstein and Pritchard (2018); Ghiasi et al. (2017); and Popescu and
Predescu (2016)—found that health care providers are pursuing increasingly
comprehensive strategies to transform health and well-being in their communities due to
the disruption of markets by the lack of price transparency and the prevalence of health
care insurance. Over the past few decades, public concerns about health care systems
brought about some difficult tasks for political leaders. A global epidemic of health care
reform propelled governments to cope with the challenge of meeting the demands of
health care systems (Klein, 1993). In a health care service environment of tension and
division of labor, the most basic challenge is the performance of employees (Platis,
Reklitis & Zimeras, 2015). Clinical and non-clinical health workers form the backbone
of any health system (Okello & Gilson, 2015). The key principles for improving health
care quality are balancing the work system and encouraging the active and adaptive role
of workers (Carayon et al., 2014).
In the empirical literature, researchers found that performance of public sector
employees is critical to the delivery of services and that public service managers are
challenged with a lack of ready made answers to performance management (Arnaboldi,
Lapsley & Steccolini, 2015; Knies, Boselie, Gould-Williams, & Vandenabeele, 2017;
Platis et al., 2015; Van Dooren, Bouckaert, & Halligan, 2015; Rua & Correia, 2017). The
performance of public sector employees is critical to the delivery of services, public
policy, and reform initiatives. Platis et al. (2015) contended that, as a phenomenon,
performance is very much related to aspects of quality, effectiveness, and knowledge
management. On the other hand, performance as a phenomenon is financing,
management and development of the organization. Rua and Correia (2017) asserted that
in order for organizations to survive, they must have the ability to respond to a growing
number of needs in the practices and outcomes of public health care systems.
Mergers and acquisitions are important phenomena due to market-oriented health
care structure of health systems (Antos, 2015). In 2013, the consolidation of several
investor-owned operations resulted in an excess number of hospitals involved in
acquisitions in the United States (Irving Levin, 2016). Despite the increase in mergers
and acquisitions, clients of hospital services may be in an uncomfortable situation
because customers have less bargaining power due to the reduction of options (Migowski
et al., 2018).
Private non-profit or for-profit hospital mergers in England are increasingly
subject to scrutiny by the Competition Markets Authority (CMA) due to reduced
competition and restriction in patient choice (Siciliani et al., 2017). The CMA law
examines the benefits and the potential adverse effects for patients after a merger. CMA
authorizes mergers that are in the overall interest of the patient with an emphasis on
clinical quality. CMA laws do not apply to state-owned health care organizations. “The
rationale for exempting public hospitals from the scrutiny of competition authorities
remains unclear (Siciliani et al., 2017, p. 14).” Policies for hospital competition
encourage public hospitals to compete on quality due to concerns that quality may suffer
as a result of mergers between public hospitals.
The National Health Service (NHS) is the most extensive, publicly funded,
singlepayer health care system in the world (NHS, 2017). In recent years, there has been
a shift in health care system efficiency across the United Kingdom, favoring primary
care, in the hope that treating people before conditions worsen will be cost-efficient and
more effective (Chevreul, Brigham, Durand-Zaleski, & Hernández-Quevedo, 2015).
However, to improve efficiency, the disproportionate amount of money tied up in
hospital care rather than primary care and community care will need to be addressed.
Currently, the United States health care system is the most expensive in the world
but ranks last of eleven nations (United Kingdom, Switzerland, Sweden, Australia,
Germany, The Netherlands, New Zealand, Norway, France, Canada and United States)
on indicators of efficiency, equity, and outcomes (Davis, Stremikis, Squires, & Schoen,
2014). Low- and middle-income countries (LMICs) face some structural problems and
inefficiencies in health systems (Paul et al., 2018).
Although the United Kingdom lags on health outcomes, it continues to rank first
overall to demonstrate strong performance (Davis et al., 2014). These rankings are based
on measures of high-performance national mortality data and on the experiences and
perceptions physicians and patients; they do not capture critical dimensions of efficiency
and effectiveness that might be obtained from administrative data or medical records
(Davis et al, 2014).
In the United States, disparities in access to services signal the need to expand
insurance to cover the uninsured (Davis et al, 2014). Low- to moderate-income families
are eligible for financial assistance to get coverage under the Affordable Care Act (Davis
et al, 2014). According to Sessions, Hassan, McLeod and Wieland (2018), the number of
uninsured adults in the United States dropped to 12% in 2016, down from 20% in 2010.
Information technology is an essential foundation for the transformation of the
health care industry in today's society (Wager et al., 2017). The United States is
beginning to close the gap with other countries that have led on adoption of health
information technology due to the enactment of the American Recovery and
Reinvestment Act (ARRA) of 2009 (Davis et al., 2014). Adoption is the decision of an
organization or community to commit to and initiate an evidence-based intervention
(Brownson et al., 2017). As this sector of U. S. society strives to provide quality care,
contain costs, and ensure adequate access, the need for quality information in health care
has never been higher (Wager et al., 2017). A learning health care system is the system
in which "science, informatics, incentives, and culture are aligned with continuous
improvement and innovation, with best practices seamlessly embedded in the delivery
process and new knowledge captured as integral by-product of the delivery experience”
(Britto et al., 2018, p. 1).
Health care providers are creating health systems that include updated technology
along the new spectrum to thrive in the modern era of health care delivery (Wager et al.,
2017). The new revelation of business model changes, incentives, and processes follow
on the heels of the increase in electronic health record adoption prompted by the United
States federal government’s Meaningful Use program (Wager et al., 2017). United States
health care providers are encouraged by incentives from the federal government to use
integrated medical records and information systems that are accessible to patients and
providers (Davis et al., 2014). Initiatives and opportunities promoted by the government
have played vital roles in the adoption and application of the technologies in health care
(Wager et al., 2017). These incentives are opportunities the American Recovery and
Reinvestment Act of 2009 (ARRA) initialized for the U. S. Department of Health and
Human Services (DHHS), partner agencies and the States to improve health care through
health information technology (HIT) (Davis et al., 2014). These incentives promote
meaningful use of electronic health records (EHR) and are distributed through Medicare
and Medicaid payments systems to eligible professionals and hospitals (Davis et al.,
2014).
Today’s health care providers across the continuum of care are contingent on
reliable HIT to aid in managing population health efficiently while reducing costs and
improving quality patient care (Wager et al., 2017). Integrated and less
resourceconsuming approaches grounded on existing domestic institutions and networks
aims to strengthen the local health system (Paul et al, 2018). To date, the United States
Veteran's Health Administration (VHA) is the most significant integrated health care
system in the U.S. (VHA, 2018). The cost of ARRA's stimulus package between 2009
and 2019 was estimated to be $831 billion. The rationale of the Act was based on
Keynesian economic theory, which held that demand should be increased by the
government to boost growth (Amadeo, 2018). Health care administrators must think of
strategic initiatives to take advantage of access to real-time and relevant clinical
information (Wager et al., 2017).
Ghiasi et al. (2017) noted the nonexistence of prominent organizational behaviors
in health care systems such as motivation, conflict, leadership, and culture. Scholars
(Chen et al., 2015; Holt, 2012; & Kertoack et al., 2007) identified factors such as
motivation, conflict leadership, organizational culture, and organizational equity as a
significant predictor of hospital performance in organizational behavior studies. There is
a gap in the literature in the area of organizational behaviors. Ghiasi et al. (2017)
recommend further examination to see the impact on employees' motivation,
organizational culture, conflict, organization climate, power in the organization,
regulatory and equity. Systematic evaluations on health system practices and outcomes
will provide a meaningful contribution to the empirical literature in this area and will
provide managers, lawmakers and researchers with current knowledge in the context of
public health service (Ghiasi et al., 2017).
A review of the empirical literature will provide background information and
insight into the research hypothesis: There is a correlation between growth opportunities,
organizational culture and monetary compensation on employee motivation. The results
of the research will contribute to the change process in public health care organizations.
Background
A global epidemic of health care reform propelled governments to cope with the
challenge of meeting the demands of increasing health care systems while limiting the
demands on their budget (Klein, 1993). During the mid-1980s, policy makers in many
countries attempted various reforms of their health care systems (Maynard & Bloor,
1995). Societies have inadequate resources to satisfy all their citizens’ wants and needs
(Anderson, Heidenreich, Barnett, Creager, Fonarow, Gibbons, & Masoudi, 2014).
Therefore, from a societal policy perspective, a decisive health care goal should be to
achieve the best health outcomes with predetermined health care resources (Anderson et
al., 2014).
Single-payer systems rely on existing taxation systems and offer governments a
high degree of control over the total expenditure on health (Hussey & Anderson, 2003).
For example, Britain’s National Health Service (NHS) is a state-administered health care
system financed by general revenues (Giaimo, 2001). On the other hand, the United
States health care system is private and relies on voluntary fringe benefits offered by
employers and insurers (Giaimo, 2001). The health care spending disparities between
Britain and the United States are remarkable when one considers that Britain was able to
extend access to care to the entire population while the United States has not (Giaimo,
2001).
This study used secondary data from England to analyze factors that could
correlate with inefficiencies in practices and outcomes in public health care systems.
Specifically, the study sought to determine whether growth opportunities, organizational
culture, and monetary compensation correlated with employee motivation. The study
was based on a published survey (non-peer reviewed), the NHS Staff Survey, England,
that is available online (http://www.nhsstaffsurveys.com/Page/1056/Home/NHS-
StaffSurvey-2018/).
The purpose of health systems is to improve and protect health (World Health
Organization, 2000). The external threat of managed care prompted many consolidation
transactions in the mid-1990s. In 1996, there were 768 hospital facilities involved in
consolidation transactions in the United States (Brown et al., 2012). Over the next few
years, consolidation transactions in the United States dropped between 30 and 50
transactions per year. The declines were occurring mainly due to microeconomic issues
facing smaller hospitals and some larger systems. Examples of these microeconomic
issues are competition and loss of access to capital.
Mergers often cause employees to have questions about the organization’s future
(Vetter, 2014). Health care organizations may experience low motivation from
employees when the employees do not know what is expected of them during a
consolidation transaction (Humphreys, Haden, Oyler, Cooke, Zhao, Hayek, & Little,
2012). Mergers and acquisitions can disrupt relationships between employees and
managers. Disruption in an organizations structure creates uncertainty and stress among
managers and employees. Health care employers must adapt to a variety of cultural and
technological changes if they want to retain and attract talented employees, improve
employee performance, and maintain a competitive advantage (O'Neill, 2017).
The culture of newly merged health care organizations is hard to develop during
the post-merger integration when a merger does not bring the anticipated benefits
(Ovseiko, Melham, Fowler, & Buchan, 2015). The violation of an organization’s cultural
values makes it difficult for employees to be motivated, which can lead to failure in a
post-integration stage (Jacobs, Arjen, & Christe-Zeyse, 2013). Merging two
organizations with different cultures create “cultural indigestion” when cultures are not
compatible (Schein, 1990, p. 117).
Since 2010, over 300 health care organizations in 47 states have merged (Niggel
& Brandon, 2014). Smaller nonprofit organizations are vulnerable and will be targeted
for investor-owned acquirers (Ault, Childs, Wainright, Young, & Williams, 2011). In the
1990s, a concentration of hospitals in large groups ended up reflecting on the rise of the
prices set by insurance companies and health insurance providers (Migowski, Migowski,
& Libânio, 2018). By 2006, the privatization of Hospital Corporation of America
affected 176 acute-care hospitals (Irving Levin Associates, 2016). In 2010, particularly
after the Affordable Care Act, the increase of investments led to new infusions and
acquisitions to reduce risk and cost (Migowski et al., 2018).
Organizations face many challenges when there is a shift that enables them to
make changes (Jacobs et al., 2013). According to WHO (2000), the four principal
functions health systems should undertake are to (a) provide services; (b) generate human
and physical resources that make service delivery possible; (c) raise and pool resources
use to pay for health care and (d) set and enforce the rules of the game and provide
strategic direction for all the different actors involved. The evolution of economic
globalization in the 21st century has critical features, such as mobility and liquidity of
capital, interlocking connections of currency systems to control market-driven impulses
that benefit investors at the expense of ordinary people (Reisch, 2013). These features
come from financial crises that have a trickle-down effect, such as the 2010 Affordable
Care Act (Reisch, 2013).
An organization must understand the importance of using multiple levels of
management to complete the merger/acquisition process to lead them through a
successful merger. Conflicts of interest play a significant role in the success of a
merger/acquisition (Ng & Thorpe, 2010, p. 471). Shibayama, Tanikawa and Kimura
(2011) suggested using a core group of employees to build a strong foundation for the
long haul of the company, during and after the merger and acquisition.
Organizations must consider factors such as environmental conditions, employee
perceptions, management influences, and employees’ motivation, along with the cultural
setting during a merger to determine the failure or success of the merger (Wagner &
Garibaldi, 2014). Models such as Hackman and Oldham's job redesign model can reduce
turnover rates and improve job satisfaction, thereby increasing employee motivation
(Chen & Mykletun, 2014). Inadequate employee identification causes low motivation
(Humphreys et al., 2012). Baek-Kyoo and Ready (2012, p. 279) identified supervisory
career support as a critical factor that affects employee's career development.
The MHT and the SIT guided the study. The motivator or intrinsic approach
explains that employees tend to describe satisfying experiences regarding factors or
motivators that were intrinsic to the content of the job itself (Ramlall, 2004). These
factors include variables such as achievement, recognition, the work itself, responsibility,
advancement and growth. Conversely, hygiene or extrinsic factors are dissatisfying
experiences that result from non-job-related factors such as salary, company policy,
supervisory styles, and co-worker relations. Therefore, managers can bring about peace
in the workplace when they seek to eliminate factors that create job dissatisfaction but not
necessarily motivation.
Problem Statement
A global epidemic of metamorphosed conglomerated health care systems is
changing the face of public health care organizations. The problem is that public health
care organizations merge into systems but the environment does not merge with the
organizational structure. In other words, the culture of each organization has not been
formed under the new system, which leads to internal organizational behavioral practice
and workplace outcome issues. With that said, it is difficult for each merged organization
to bring its own culture into a new system. Research found that employee motivation is
hard to achieve when there are issues within the internal structure of the new
organization. The empirical literature supports the performance of public sector
employees and how critical they are to the delivery of services (Arnaboldi, Lapsley, &
Steccolini, 2015; Knies, Boselie, Gould-Williams, & Vandenabeele, 2017; Pinheiro et al.,
2017; Ghiasi et al., 2017). But employees lose motivation when they do not know where
they fit in the new system (Humphrey et al., 2012; Ovseiko et al., 2015; Jacobs et al.
2013; Niggel & Brandon, 2014; Ault et al., 2011). Therefore, I studied the behavior of
employees who work in these systems. My research hypothesis was as follows: There is
a correlation between the independent variables of growth opportunities, organizational
culture, and monetary compensation and the dependent variable of employee motivation.
Additional research on organizational behavior in the context of consolidated
public health care system practices and outcomes will provide a meaningful contribution
to the empirical literature in the area of public administration and will provide managers,
policymakers, and researchers with current knowledge in the perspective of public health
services (Ghiasi et al., 2017). The general problem was that public health care providers
must be competent in developing and implementing strategies to improve organizational
performance (Wager et al., 2017). The specific problem was that public health care
systems face structural issues and inefficiencies in internal practices and outcomes
(Ghiasi et al., 2017).
Purpose Statement
The purpose of this correlational study was to examine the statistical relationship
between growth opportunities, organizational culture, monetary compensation and
employee motivation. Growth opportunities are the real opportunities for a person to
experience personal growth, learn a new skill, undergo training in new techniques, and
gain new professional knowledge (Alshmemri, Shahwan-Akl, &Maude, 2017).
Organizational culture is described by Schein (1985) as a pattern of “assumptions that the
group learned as it solved its problems of external adaptation and internal integration that
worked well enough to be considered valid”. The culture is taught to new members “as
the correct way to perceive, think, and feel in relation to those problems” (p. 12).
Monetary compensation constitutes all forms of benefits and payments at a workplace,
such as wage or salary increases or unfulfilled expectations of wage or salary increases or
decreases (Alshmemri, Shahwan-Akl, & Maude, 2017). Employee motivation is the
level of energy, commitment, and creativity that a company’s workers bring to their jobs
(Inc.com, 2017).
The data type was a consensus questionnaire. The researcher was granted
permission from the National Health Service England’s (NHS) Survey Coordination
Centre to use its 2016 archival dataset (NHS, 2017). The data collection instrument was
paper and online questionnaire containing a set of core questions (NHS, 2017). A sample
size of 3,033 health care workers was from two acute hospital trust sites in England. The
type of power analysis used for the study was post hoc, two tails, with an effect size
of .50, error probability of .05, with a total sample size of 3,033 using Point-Biserial
Correlation Coefficient model statistical t test. The non-centrality parameter was 31.796;
Df was 3031, Critical t was 1.96, and power (1-β err probability) 1.00. A Cronbach’s
alpha analysis was performed on all items of the instrument to check for validity and
reliability. The raw data were analyzed using a Pearson correlation and a descriptive
analysis. The data were summarized using a descriptive statistical test to test the
hypothesis.
Research Hypotheses
1. RH1—Quantitative: There is a correlation between the independent variables growth
opportunities, organizational culture, monetary compensation and dependent variable,
employee motivation. Employee motivation (dependent variable) was operational
through the following question in the questionnaire: I look forward to going to work. A
Pearson Biserial Correlational Coefficient model statistical test was used to test each
hypothesis. The significance level was .05 or less to reject the null hypothesis.
Research Null Hypothesis 1:
There is a correlation between growth opportunities and employee motivation.
Growth opportunity (independent variable) was operational through the following two
questions in the questionnaire: my training, learning and development has helped me to
do my job more effectively and my training, learning and development has helped me to
stay up-to-date with professional requirements.
Hº: There is no correlation between growth opportunities and employee
motivation.
Hª: There is a correlation between growth opportunities and employee
motivation.
A Pearson Correlational statistical test was used to test the hypotheses. The
significance level was .05 or less to reject the null hypothesis.
Research Null Hypothesis 2:
There is a correlation between organizational culture and employee motivation.
Organizational culture (independent variable) was operational using the following
questions in the questionnaire: senior managers here try to involve staff in important
decisions and communication between senior management and staff is effective. Hº:
There is no correlation between organizational culture and employee motivation.
Hª: There is a correlation between organizational culture and employee
motivation.
A Pearson Correlational statistical test was used to test the hypotheses. The
significance level was .05 or less to reject the null hypothesis.
Research Null Hypothesis 3:
There is a correlation between monetary compensation and employee
Motivation. Monetary compensation (independent variable) was operational through the
following questions in the questionnaire: my level of pay and the recognition I get for
good work.
Hº: There is no correlation between monetary compensation and employee
motivation.
Hª: There is a correlation between monetary compensation and employee
motivation.
A Pearson Correlational statistical test was used to test the hypothesis. The
significance level was .05 or less to reject the hypotheses.
Theoretical Framework
For this study, I reviewed pertinent research studies for theories and analytic
models that were relevant to the research problem. The theoretical framework
strengthened the outline with an explicit statement of theoretical assumptions of the
research study, specifying which key variables influenced the phenomenon and
examining how the key variables differed and under what circumstances. The theoretical
framework explained the meaning, nature, and challenges associated with the
phenomenon that were experienced but unexplained (USC, 2018).
Herzberg’s MHT and Tajfel and Turner’s SIT guided the study. Vijayakumar and
Saxena noted that Herzberg's method is impractical for explaining how job satisfaction
and motivation address organizational culture in the workplace (Vijayakumar & Saxena,
2015). Therefore, the study used the SIT to support the independent variable,
organizational culture. The MHT argued that people became motivated when challenged
in the work place with more responsibilities (Herzberg, 1959). Herzberg’s two-factor
approach: motivator (intrinsic) and hygiene (extrinsic) guided the study. The motivator
—or intrinsic approach—explains job satisfaction and the hygiene—or extrinsic approach
—explained job dissatisfaction in the workplace (Herzberg, 1959).
Tajfel and Turner’s SIT involves individuals and social groups. The identity of
individual employees tends to get lost during restructuring processes (Ghafournia, 2015).
Leaders must control their language when delivering messages to employees so that their
message will influence the employees to meet goals and desired expectations
(Ghafournia, 2015). Cultural competence is a crucial component of SIT because no one
culture should be superior to another (Torres, 2015). The identity-marking function of
speech is as important as the communicative one (Ghafournia, 2015). People can quickly
become unmotivated under leaders who use words or phrases that sound foreign to them,
no matter what their intentions are (Ghafournia, 2015). Language is communication.
Every organization deals with social identity in one form or another, for example,
educational levels, social classes, ethnicity, and language (Ghafournia, 2015).
Organizations can strengthen their employees’ motivation by using strategies and
techniques to address culture using the SIT during and after a merger and acquisition
(Ghafournia, 2015).
Nature of the Study
Existing data can be used to address research questions (Johnston, 2017, p. 621).
In this case, using secondary data from the NHS Survey Coordination Centre, England, a
quantitative, descriptive design was used to analyze factors that correlate with employee
motivation. The data were drawn from a more extensive study that was used by NHS to
test staff experiences, to monitor change over time, and to identify variations between
different staff groups (NHS, 2017). This research design was logical for the study for
providing information on what is or what was from the questions asked of the participants
(Brickman & Roy, 1998). Some researchers have asserted the benefits of reusing shared
data, although reusing data might not be in the norm in every discipline (Yoon, 2017).
As a result of technological advances, a vast amount of collected, compiled, and archived
data is easily accessible and becoming more common in research (Johnston, 2017).
Secondary data is a viable option for researchers who may have limited resources and
time (Johnston, 2017).
The purpose of the NHS 2016 Staff Survey was to collect staff views and
experiences of working in their local health care organization and to provide information
for deriving national and local performance indicators (NHS, 2017). The survey offered
an opportunity for public health care organizations to survey their staff consistently and
systematically to build up a picture of staff experience and, with care, to compare and
monitor change over time and to identify variations between different staff groups (NHS,
2017). The data were collected from a sample of 3,033 health care workers. The
population consists of two NHS England Foundation Trust sites: a general hospital
located in a metropolitan area and a university hospital located in a suburban area of
England. The General Hospital-Acute Trust located in the metropolitan area of England
was built in 1970. This public hospital replaced three other public hospitals that were
built in the late 1800s. The University Hospital-Acute Trust located in a suburban area of
England was founded in 1828. In 1898 the university hospital was acquired and became
City Hospital.
The descriptive design describes and measures the statistical correlation between
employee motivation and growth opportunity, organizational culture and monetary
compensation using a Pearson correlation. Employee motivation (dependent variable)
was operational through the following question in the survey: I look forward to going to
work. Growth opportunities (independent variable) were operational through the
following questions in the survey: My training, learning or development has helped me
to do my job more effectively and my training, learning or development has helped me to
stay up-to-date with professional requirements. Organizational culture (independent
variable) was operational through the following questions in the survey: Communication
between senior management and staff is effective; and senior managers here try to
involve staff in important decisions. (NHS, 2018). Monetary compensation (independent
variable) was operational through the following questions in the survey: The recognition I
get for good work and my level of pay.
Operational Definitions
Employee motivation (dependent variable) was operational through the following
questions in the questionnaire: I look forward to going to work.
Growth opportunities (independent variable) was operational through the
following questions in the questionnaire: my training, learning or development has helped
me to do my job more effectively and my training, learning and development has helped
me to stay up-to-date with professional requirements.
Organizational culture (independent variable) was operational through the
following questions in the questionnaire: senior managers here try to involve staff in
important decisions and communication between senior management and staff is
effective.
Monetary compensation (independent variable) was operational through the
following items in the questionnaire: the recognition I get for good work and my level of
pay.
Conceptual Definitions
Conglomerate is having an organization firm in more than one industry in a given
year (Hoberg & Phillips, 2017).
Employee motivation: The level of energy, commitment, and creativity that a
company’s workers bring to their jobs (Inc.com, 2017).
Growth opportunities: The real opportunities for a person to experience personal
growth, learn a new skill, undergo training in new techniques, and gain new professional
knowledge (Alshmemri et al., 2017).
Learning Health care System is defined by the Institute of Medicine as a system
in which "science, informatics, incentives, and culture are aligned with continuous
improvement and innovation, with best practices seamlessly embedded in the delivery
process and new knowledge captured as an integral by-product of the delivery
experience” (Brownson et al., 2017, p. 34).
Metamorphose is transformation and change (Dinmohammadi et al., 2017).
Metamorpho sis is defined as a major change in the appearance or character of
something (Merriam-Webster, 2018).
Monetary compensation: All forms of benefits and payments at a workplace
such as a wages or salary increases or unfulfilled expectations of wage or salary
increases or decreases (Alshmemri et al., 2017).
Organizational culture: Organizational culture is a pattern of shared underlying
assumptions that the group learned as it solved its problems of external adaptation and
internal integration that has worked well enough to be considered valid and, therefore, to
be taught to new members as the correct way to perceive, think, and feel in relation to
those problems (Schein, 1985, p. 12).
Assumptions
Assumptions were used correctly to avoid problems regarding the validity and
power of the results (Ernst & Albers, 2017). This study discussed theoretical and
statistical assumptions. The motivation-hygiene and social identity theories framed the
study. Theoretical assumptions must be made about the world around us to understand
science better. Science will have less value if these assumptions are not factually
accurate (Miner, 2015). Assumptions that produced a degree of solid understanding were
used. A clear explanation of any missing data was provided. The explanation described
why the missing data did not undermine the validity of the final analysis.
The first theoretical assumption assumed that specific natural groupings of
phenomena exist (Miner, 2015). The dependent and independent variables were grouped
using operational variables. The second theoretical assumption controlled the scientific
observation so that association was attributed correctly. The specific research problem of
interest was public health care systems face structural issues and inefficiencies in
practices and outcomes. The two theories permitted the researcher to intellectually
transition from merely describing the phenomenon observed to generalizing about
various aspects of that phenomenon (USC, 2018).
Third, theoretical and empirical literature supported the determination of the
research hypotheses and the correlations that exist. And finally, trustworthiness was
assumed for the human processes of perceiving, remembering, and reasoning. The
peerreviewed research provided a rationale for the area of study. The results of the study
will offer students and scholars current knowledge and gaps found in the research study
for future studies. According to Miner (2015) the purpose of theory is to achieve an
objective, rational, replicable result, which will be convincing to those who are
knowledgeable in the area of study. Gall, Gall and Borg (2017) contended that the
relevance of the theory must be applied to the research hypotheses to produce the
appropriate conclusion.
Limitations and Delimitations
Indications of internal consistency were reported along with the alpha coefficient.
When a scale was composed of a considerable number of items, factor analysis was
performed along with the application of appropriate internal consistency estimation
method. The adoption of this approach was mainly minimized and guarded against the
uncritical use of Cronbach's alpha coefficient (Aaron, 2014).
The researcher was not involved in the data collection process. Information that
was missing from the dataset was not available to the researcher due to confidentiality
reasons. Also, a lack of authenticity from respondents further limited the researcher from
knowing who to contact with questions concerning the dataset. Researchers can avoid
most limitations of secondary data analysis by ensuring a match between the research
question or hypotheses and the existing data (Johnston, 2017).
Significance of the Study
Metamorphosed conglomerated public health care systems exert a strong
influence on health services, particularly in quality care, cost and public policy. This
study sought to indicate whether growth opportunities, organizational culture, monetary
compensation fundamentally contributed to employee motivation. The study is expected
to inform policymakers, hospital administrators, researchers, human resource managers,
and other stakeholders of various approaches to improve health care services and
practices (Brownson et al., 2017 & Cho, Lee, & Kim, 2014).
Research on organizational behavior in the context of consolidated health care
system practices and outcomes is expected to provide a meaningful contribution to the
empirical literature in the area of public administration. The study is also is expected to
provide managers, policymakers and researchers with current knowledge in the
perspective of public health services (Ghiasi et al., 2017). Policymakers can introduce
“vertical competition between integrated care pathway providers” since “horizontal
competition can hinder vertical integration by increasing the segmentation of care
pathways” (Siciliani et al., 2017, p. 109). Further amendments and implementation of
laws can improve the performance of health care systems (Davis et al., 2014). Health
information technology can inform stakeholders about the experiences of other countries
that may be relevant to their situation and report the comparative analysis of health
systems (Chevreul et al., 2015).
This study is expected to provide systematic reviews of important and meaningful
practices and outcomes. Stakeholders will have insight into conditions that can
strengthen the health care system and workplace environment (Echoles, 2016). Finally,
the study is expected to contribute to the field of health care by improving patient care,
increasing health care executives’ knowledge on implementing procedures that reduce
turnover rates, and improve job satisfaction, thereby increasing employee motivation and
the quality of care (Echoles, 2016; Chen & Mykletun, 2014). The study contributes to
the motivational-hygiene theory by explaining the phenomena of job satisfaction in the
context of practices and outcomes in public health care systems (Alshmemri,
ShahwanAkl, & Maude, 2017). The study also contributes to the social identity theory
by explaining the phenomena of dynamics of language and speech in the context of
practices and outcomes in public health care systems (Hogg, 2016).
Summary
This chapter discussed the background of mergers and acquisitions and internal
organizational behaviors. A global epidemic of metamorphosed, conglomerated health
care systems changed the face of public health care organizations. Metamorphose is
defined as transformation and change. Conglomerate is defined as a number of different
parts that are grouped together to form a whole but remain distinct entities. Over the past
few decades, public concerns about health care services, cost and quality brought about
some difficult tasks for public administrators. The most basic challenge of health care
service environments of tension and division of labor is the performance of employees.
Health workers form the backbone of any health care system.
The problem is, public health care organizations merge into new systems, but the
culture for each merged organization has not been formed under the new system. Public
administrators, health care workers and the Department of Health and Human Services
are affected when there are issues in health care behavioral practices and performance
outcomes. Research found that employee motivation is hard to achieve when there are
issues within the internal structure of a new system. Herzberg’s motivation-hygiene and
Tajfel and Turner’s social identity theories were used as the foundation. This
correlational study examined the statistical relationship between growth opportunities,
organizational culture, monetary compensation and employee motivation.
Secondary data were obtained from the National Health Services Survey
Coordination Centre in England. Scholars have extolled the benefits of reusing shared
data although reusing data might not be in the norm in every discipline. Models were
implemented and evaluated within academic centers to show that the translation of
science to practice is an academic discipline with methods and outcomes that can be
assessed like any other discipline. The sample consisted of 3,033 health care workers
from two hospitals located in the United Kingdom. The data were examined using Point-
Biserial Correlation Coefficient model statistical t test. Cronbach’s alpha was used to test
the reliability and validity of the questionnaire items. A descriptive frequency test was
used to summarize the results. The study is expected to affect social change by informing
the Department of Health and Human Services, health care organizations and public
health administrators of various strategies that can be used to improve internal
organizational practices performance outcomes. Researchers, community organizations,
health care workers, community members, patients and funders are expected to benefit
from the recommendations.
Chapter 2: Literature Review
Introduction
This chapter is a review of the empirical literature. The literature review provided
public administrators with insight into models and theories that can be replicated to
strengthen health care systems and workplace environments. The purpose of the review
was to examine practices and outcomes of organizational behaviors in public health care
systems, particularly the health care system of the United Kingdom. According to Henry
(2017), public administration is a combination of theory and practice that is meant to
promote a greater understanding of government and its relationship with the society it
governs. The purpose of public administration is to encourage public policies in response
to social needs and to institute effective and efficient managerial practices.
Globally, public health care organizations promoted the transformation of health
care systems towards consolidated and integrated care by using the people-centeredness
approach, which met the needs of its citizenry (Nuti, 2017). A study on public attitudes
toward health care policy conducted by Azar, Maldonado, Castillo, and Atria (2018)
found that citizens across socioeconomic groups in 29 countries were motivated to
support state-funded health care. Evidence of the impact of the growing body of work on
public involvement in the health care policy process remains scarce (Conklin, Morris, &
Nolte, 2015). A patient and public involvement initiative was implemented in the United
Kingdom for holding policy-makers and health care provider organizations accountable
for planning and delivering health services (Harper, 2015).
As explained by Mossialos, Wenzl, Osborn, and Sarnak (2016), the Parliament,
Secretary of State for Health, and the Department of Health in England are responsible
for general policy and health legislation. For the discussion that follows, I will be
discussing research conducted by Mossialos et al. (2016) drawn from the 2015
international profiles of health care systems. The Secretary of State is responsible for
promoting comprehensive health service, free of charge for those who do not have prior
charges in place. The National Health Service Constitute provides rights for eligible
participants. Although the Department of Health oversees the health systems, NHS
England is responsible for the day to day operations, including the budget. Coverage for
people using NHS services is universal. NHS is funded by general taxation and a smaller
portion is funded by the national insurance payroll tax, copayments and other minor
sources.
The scope of NHS is not defined by legislation. Patients do not have an absolute
right to receive a particular treatment. However, the Secretary of State is charged with
ensuring comprehensive coverage. Ordinary residents and nonresidents with a European
Health Insurance Care are automatically entitled to care. Illegal immigrants receive free
treatment in an emergency department for certain infectious diseases. In practice, some
of the free services received from NHS for preventive services are as follows: screening,
inpatient and outpatient hospital care, immunization, physician services, vaccination
programs, necessary dental care, rehabilitation, some eye care, mental health care, some
long-term care, home visits by community-based nurses and other long- and short-term
care, for example, physiotherapy after a stroke. According to the NHS Constitution, if
patients have a recommendation from their clinicians, they have a right to drugs or
treatment approved in technology appraisals and carried out by the National Institute of
Health and Clinical Excellence.
Publicly covered services that fall outside the purview of the NHS services
include employment examinations or insurance, such as certificates for travel.
Prescription drug copayments exemptions include “children under age 16 and those 16 to
18 in school full time; people age 60 or older; people with low income; pregnant women
and those who have had a baby in the past 12 months” (Mossialos et al., 2016, p. 50);
cancer patients, and other long-term conditions, or certain disabilities. Low-income
individuals, prisoners, pregnant women, students, and people over 60 are not liable for
dental copayments. Similarly, their vision tests are free and financial support to meet the
cost of corrective lenses is available to them. Qualified low-income people also receive
free transportation to and from provider sites.
Publicly owned hospitals in NHS England are listed as either a trust or as a
foundation. All trusts are accountable to the Department of Health and the foundations
are regulated by Monitor, an economic regulator of public and private providers.
Foundation trusts have easier access to capital funding and are able to accumulate
surpluses. Hence a reason the government in England wants all mental health, ambulance
services and hospitals to become foundation trusts in the future.
The empirical literature will be reviewed on factors that may influence
inefficiencies in practices and outcomes in public health care systems. The specific
variables that will be reviewed are growth opportunities, organizational culture, monetary
compensation and employee motivation. Herzberg’s motivation-hygiene theory and
Tajfel and Turner’s social identity theory (SIT) will also be reviewed as the foundation to
guide the study.
Literature Search Strategy
For this study, I reviewed peer-reviewed journal articles, scholarly books, and
doctoral dissertations through. Following are online databases that I searched: Theses at
Walden University, Sage Publications, ProQuest, ProQuest Dissertations, EBSCO Host,
Science Direct and Google Scholar. Other online resources included the following: Diva
Portal, Esource, BMC Health Services, International Journal of Research-Granthaalkaya,
National Health Services, World Health Organization, United States Department of
Veteran Affairs, Commonwealth Fund, Centers for Medicare and Medicaid
Services, Congressional Budgeting Office, and American Hospital Association.
I used some references that I discovered and accessed in other peer-reviewed
articles and books in the literature review. I used approximately 150 scholarly articles
from the literature review from publications within the last 5 years. Keywords searched
included mergers and acquisitions, employee motivation, job satisfaction, job
dissatisfaction, organizational culture, growth opportunities, monetary compensation,
Herzberg’s motivation-hygiene theory, social identity theory, merger, and acquisition in
health care facilities, health systems, quantitative approach, management, health care
facilities and mergers, secondary data, conglomerate and metamorphose.
Theoretical Foundation
A theory is a generalization that specifies the relationships between factors. It tells
a story about a phenomenon by emphasizing the nature of causal relationships,
identifying what comes first as well as the timing of events (Miner, 2015). A theory is
based on a set of logically interconnected arguments that are created to facilitate
understanding.
Motivation-Hygiene Theory
Herzberg’s motivation-hygiene theory (MHT) was developed to highlight the role
of job satisfaction to determine worker motivation (Riggio, 2016, p. 199). Herzberg
proposes that the traditional, single-dimension approach to job satisfaction with its
continuum ends ranging from job dissatisfaction to job satisfaction is wrong, and that job
dissatisfaction and job satisfaction are two separate and independent dimensions.
Herzberg arrived at the two-factor theory after surveying white collar professional
workers who were asked to describe what made them feel exceptionally good or bad
about their jobs. The results showed that the factors were clustered into two categories:
job satisfaction (motivators) and job dissatisfaction (hygiene). Motivators are inherent in
the work itself and are related to job content. Examples of motivating factors are the type
of work, the level of responsibility associated with the job, recognition opportunities,
personal achievement and advancement (Riggio, 2016, p. 200). Hygiene is related to job
performance. Examples of hygiene factors are benefited, working conditions (both
physical and social) supervision, company policy and base salary.
Based on the MHT, the motivator factor relates to the rewards, flow from the
nature of the work and the outcome performance of that work (Herzberg, 1959, 1987).
Management often confuse motivator and hygiene factors by using the hygiene factor as a
way to motivate employees, when, in fact, this factor contributes a small fraction of
employee motivation. The hygiene approach takes less effort on the part of management
to raise salaries than it does to redesign jobs or to develop company policies for
satisfaction (Ray, 2016). One of the critical ingredients in employee’s performance and
productivity is motivation (Shirol, 2014).
I reviewed a plethora of studies from the empirical literature to validate the
motivation-hygiene theory. Vijayakumar and Saxena (2015) contended that the approach
in Herzberg’s MHT has insufficiencies when explaining job satisfaction and motivation
in the workplace. Vijayakumar and Saxena argued that the money factor that falls under
Herzberg's hygiene approach is significant in job satisfaction and influence socio-cultural
milieu as opposed to being a motivator or intrinsic factor that produces job satisfaction.
Vijayakumar and Saxena found that the theory is impractical in explaining how job
satisfaction and motivation address organizational culture in the workplace. Further
research on organizational culture is needed (Vijayakumar & Saxena, 2015).
Social Identity Theory
Group cultures, rational and developmental, contribute to organizational
identification (Ismail, Baki, Omar, & Bebenroth, 2016). Employees that attach
themselves to a group during mergers and acquisitions may feel less attached to the
merged organization and are less likely to identify themselves with the new organization.
Achieving positive post-merger identification is the goal of M & A integration (Joseph,
2014). Methods such as assessing each organizations identity in the post-merger phase
and integrating strategies such as holding monthly meetings, removing old brand and
distributing new brand materials to employees that match the structure reduced
differences between merged partners. Joseph (2014) suggests that the initiation be
located is in a low-threat environment.
Underlying organization identification in shaping identification during a
significant organizational change can produce self-enhancement and continue to
influence identification when measured by attractiveness of perceived external prestige
and organizational identity during the merger (Elstak, Bhatt, Van Riel, Pratt, & Berens,
2015). Managers must work towards reducing uncertainty by enhancing employee’s
selfesteem and ensuring member’s identification surrounding mergers. Managers must
be clear with explaining who we are as the merged organization which will help reduce
uncertainty around the merger. Further research to explore how interdepartmental
differences influence responses to a merger is needed (Elstak et al., 2015).
Cho, Lee, and Kim (2014) examined the relationship between employee
perceptions of relative deprivation and their turnover intentions during a merger and
acquisition process. The findings showed that egoistic relative deprivation predicts
employee turnover intentions. Cho et al. defines egoistic relative deprivation "as people's
feelings of deprivation due to their dissatisfaction with their position as an individual"
(Cho et al., 2014, p. 421). Employees who feel deprived of an individual or a group level
are less likely to identify with the new organization. Further research in a different
setting on how merger types affect employee identification is needed.
Employee Motivation
Employee motivation is defined as the level of energy, commitment, and
creativity that a company’s workers bring to their jobs (Inc.com, 2017). Motivation is the
desire of individuals to act or behave in certain ways (Okello & Gilson, 2015). The
analysis of this dependent variable will contribute to the literature by identifying
opportunities for further research and policy discussions about how to influence
employee motivation in the public health sector to support quality deliveries of health
care services. Health systems must provide incentives to add to intrinsic motivation
(Karlsberg, Schaffer, Sussex, & Feng, 2015). Employees who are given opportunities for
ownership value themselves more and are motivated to indulge them in creative ideas
(Das, Byadwal, & Singh, 2015).
The value of workplace trust relationships is critical in influencing intrinsic
motivation of health worker performance (Okello & Gilson, 2015). Good management
practices, resources, professional development activities, employee trainings and culture
play critical roles in establishing trusting relationships that promote intrinsic motivation.
Rewards and recognition and working conditions motivate employees when there is clear
communication with management (Ray, 2016). Employee recognition results in job
satisfaction and motivates employees to perform better which, in turn, instills belief in
them that the longer they are committed to their goals the results will lead to promotional
opportunities. Employees are motivated to improve job satisfaction when there is a
balance between intrinsic and extrinsic motivation (Hee & Kamaludin, 2016).
Enhancement in job performance can improve employee motivation when motivational
programs are designed to assist employees in achieving better job performance.
Yeboah and Abdulai (2016) contended that work shifts to cover a 24-hour period,
seven days a week with minimum wage pay rates, lead to job dissatisfaction and high
turnover rates. Managers must continually seek effective ways to satisfy employees by
using positive factors to motivate employees to boost job satisfaction for business
productivity and profit. The most significant motivator for employees to achieve higher
performance and job satisfaction is monetary compensation and career development
opportunities. Managers must converse with employees (one-on-one) to gain an
understanding of what matters to them and for managers to get rid of things that annoy
employees. One way managers can motivate employees is by developing a culture of
respect, fair treatment, recognition, and engaging employees with more significant
responsibilities for planning their work.
Between $1.4 and $2.1 billion is what it costs health care organizations and
society when registered nurses leave the workplace (Echoles, 2016). According to
Echoles (2016) nurses are dissatisfied with their jobs due to factors such as pay, long
hours, stress, staffing issues, and opportunities for career development, which affect
motivation. Strategies that managers and leaders can use based on the results of Echoles
study are better communication with employees; involve nurses in the decision-making
process when it comes to scheduling, offer benefit programs, workplace diversity
initiatives and flexibility in schedule. Organizations can help professionals and patients
to collaborate more effectively by using elements such as emphasizing on non-hierarchal,
multidisciplinary collaboration, staff ability to model desired behaviors of recognition
and respect, commitment to rapid action (translate research into practice), and by
collecting data constantly to reflect on outcomes for improving methods (Renedo,
Marston, Spyridonidis, & Barlow, 2015).
Marete (2016) noted that determinant factors to employee disengagements are
recognition and praise, leadership styles, performance acknowledgment of one's
performance, fairness with other employees, micromanagement, opportunities to engage
in a decision-making process, and communication. Marete (2016) recommends that
managers should take training on command before promotion into leadership roles to
foster good supervisor-employee relationships. Organizations must prioritize factors
such as working conditions, benefits, compensation, relationship with supervisors and
coworkers, and opportunities for growth after a merger (Gautam, 2016). Gautam found
that a merging company's dominance over the merged company leads to employees
experiencing chaos, stress, anxiety and significant differences in an employee's job
satisfaction before and after the merger. This is due to employees not being satisfied with
factors such as working conditions, advancement, and supervisor relationships, which led
to the job satisfaction before the merger.
During a post-acquisition performance, employee attitudes have an indirect
impact on managers inspiring and motivating employees with recognition and employee
advancement opportunities (Babic, Savovic, & Domanovic, 2014). Mergers influence
employee motivation because of a lack of management communication and information
sharing (Nasir & Riaz, 2016). Location change and the change of the physical
environment at the post-integration stage of a merger influence employee motivation
(Lawlor, 2013). While Lawlor's study agrees with past researchers that employees have
varying emotions and feelings during this stage of a merger, research has shown a
significant research gap in the literature concerning human resource issues that arise from
a merger.
Employee motivation and morale increases when employee autonomy is
influenced by retention post-merger (Castro-Casal, Neira-Fontela, & Alvarez-Perez,
2013). Past research shows that working conditions contribute to employee motivation in
private and public health care facilities although private facilities have better working
conditions (Castro-Casal et al., 2013). Comprehensive interventions on staff motivation
should be integrated into strategies such as quality improvement, mainly in public health
care facilities where perceptions of working conditions are viewed as the worst (Alhassan
et al., 2013). A democratized work environment, strong leadership, organizational
citizenship, career management and modification of job design can improve intrinsic
motivation in health care systems amongst health care workers (Swarna Nantha, 2017).
Organizations can use a competence management system to document employee
competence to increase employee satisfaction (Lundin, Snis, & Svensson, 2015). Using
this system can improve quality of care through increasing competence (Lundin et al.,
2015). This system can act as a support for continuous individual competence
development to increase job satisfaction. Thereby employees may be more motivated
and stay with the organization longer.
Conditions such as professions, work structures and working relationships
influence how employees engage in health care quality improvement (Gadolin &
Anderson, 2017). Positive working will increase employee engagement and can
eliminate any barriers that professions and work structures may constitute. Wass and
Vimarlund (2016) argued that the health care sector’s engagement in open innovation is
limited and recommends further research with a focus on how open innovation can be
managed in health care.
Growth Opportunities
Growth opportunities are defined as the real opportunities for a person to
experience personal growth, learn a new skill, undergo training in new techniques, and
gain new professional knowledge (Alshmemri, Shahwan-Akl, &Maude, 2017).
Organizations must have a comprehensive vision interconnected with simultaneous
clinician training, strategies targeting patient education, documentation and community
awareness to promote advance care planning for changing culture and systems (Reidy et
al., 2017). By 2030, the growth rate for health workers globally will rise to 80 million
workers resulting in a worldwide shortage of 15 million health workers (Liu, Goryakin,
Maeda, Bruckner, & Scheffler, 2017). The growth rate is driven by economic and
population growth and aging (Liu et al., 2017). This shortage will fuel global
competition for skilled health workers. Organizations should consider wages and
employment to inform recruitment and expansion planning for educational programs
related to the future health care workforce (Walton, Kim, & Weiner, 2017). Across all
allied health care workers, there is a reduction in the employment and an increase in
relative wages (Walton et al., 2017).
Organizational leaders must be aware of the impact that an employee’s
performance can have on an organization’s bottom line (Rodriguez & Walters, 2017). In
today’s global market, it is important for organizations to provide employees with
training and development opportunities, as well as, effective employee performance
assessments for improving employee engagement, morale and overall competencies.
Organizations should have a clear plan for the growth and promotion of each employee
and provide adequate training to ensure employees are equipped with current and
appropriate skills. Time and finances are more significant factors when deciding on
training methods than the effectiveness rate of those methods (Cocuľová, 2017).
Employees perceive the time that their employer is putting into their training as an
investment in them and they are more likely to stay on the job (Das et al., 2017).
Human Resource training and development is concerned with organizational
activity aimed at bettering the performance of individuals and groups in organizational
setting and to achieve the set objectives of the organization (Hammond & Churchill,
2018). Management can achieve goals by developing the skills of employees (Cocuľová,
2017). Organizational efforts on employee training and development demonstrate that
organizations are capitalizing on individuals who can commit to achieving higher levels
of responsibilities (Rodriguez & Walters, 2017). Organizations do not tend to invest
effective training techniques for part-time employees (Jaworski, Ravichandran,
Karpinski, & Singh, 2018). An organization can gain a more competitive advantage
when leaders perceive training as a tool that creates the intellectual capital (Cocuľová,
2017). Probability for individuals to effectively deliver the mission is increased when
organizations provide core proficiencies and structure throughout the employee training
and development process (Rodriguez & Walters, 2017). Consistently developing an
employee’s skills and implementing best practices prepare employees for future roles and
responsibilities (Hammond & Churchill, 2018). Education is important in getting quality
employees; therefore education spending will increase as an organization becomes more
efficient (Cocuľová, 2017). Organizations face strong internal and external competition
when searching for quality employees in today’s business environment (Cocuľová, 2017).
Organizations invest huge amounts of money into human capital because human
resources constitute the backbone of the company and the performance of the employees
ultimately increases the performance of the company (Cocuľová, 2017).
Nurses are expected to maintain registration and professional competence to participate
in continuing professional development (Coventry, Maslin Prothero, & Smith,
2015). Growth opportunity challenges that organizations may face is an employee’s
ability to participate in continuing professional development opportunities (Coventry,
Maslin Prothero, & Smith, 2015). Employees may be reluctant or prevented from leaving
their post to attend trainings or any professional development due to lack of staff
coverage. Other examples include: paid or unpaid study leave, use of personal time for
mandatory trainings and leadership issues preventing the implementation of learning to
benefit employees. Leaders must support employee attendance for continuing
professional development as an investment for the future.
Cummings and Worley (2014) identified organizational development as a set of
evidence-based ideas and practices about how the organizations can produce sustainable
high performance and human fulfillment. Leaders are responsible for selecting the best
methods, approaches, strategies, programs, implementation, and assessment venues to
achieve expected individual performance and organizational results (Rodriguez &
Walters, 2017). These ideas and practices can help managers and staff perform task more
effectively (Cummings & Worley, 2014). Globalization is rapidly interconnecting
economically, socially and ecologically. Globalization affects organizations ecologically
by “expanding their access to natural resources making the planet more susceptible to
abuse by organizations with questionable environmental practices and governments with
loose environmental regulations” (Cummings & Worley, 2014, p. 5). Organizations can
use strategies that have been found by scholars to be effective to strengthen practices in
organizational systems.
Organizations adapting to system-based change to better align physician training
with societal needs has been slow (Gonzalo et al., 2017). Physicians must move away
from traditional basic and clinical sciences and adapt to practicing in systems-based
environments. The adaptation of new practices will uncover relevance and meaning in
physicians’ education through patient-centered roles, authenticity and added value within
the health care system. A systems-based practice in medical education needs to evolve
more rapidly to better prepare physicians for practice in the 21st century. Health care
professionals are encouraged to work collaboratively due to the complexity of the health
care needs of today’s society (Decker et al., 2015). Simulation-based experiential
learning is also an effective way to promote inter-professional education teamwork
(Decker et al., 2015). Managers must have the ability to create and maintain positive
practice environments for newly graduated nurses to foster professional development and
job satisfaction to retain them in the workplace (Numminen et al., 2016). Organizations
must provide positive incentives linked to the quality of working environments by
instituting work-life balance mechanisms as a strategy to improve outcomes for health
care nurse practitioners (Misfeldt et al., 2014).
Organizational Culture
The first step when considering the roles of organizational culture in facilitating
high quality care and improve outcomes is to explain what is meant by organizational
culture (Mannion & Smith, 2017). Organizational culture is a pattern of shared
underlying assumptions that the group learned as it solved its problems of external
adaptation and internal integration that has worked well enough to be considered valid
and, therefore, to be taught to new members as the correct way to perceive, think, and feel
in relation to those problems (Schein, 1985, p. 12). It is the cornerstone of any
development in the organizational environment which includes organizational team
members and is key to leadership’s decision –making and organization accomplishment
(Jalal, 2017). The culture of an organization determines what people should say and do
and is the usual way of doing things (Gabriel, Middleton, Papastavrou, & Merkouris,
2017). Culture is a fundamental factor for explaining organization behavior and has a
consistent impact on public service motivation (Ritz & Brewer, 2013).
Organizational culture outlives founders, leaders and managers and is the most
difficult attribute to change (Serrat, 2017). Attitudes and behaviors adopted by
employees can form organizational cultures that affect its function and total well-being
(Belias & Koustelios, 2014). An organizations effectiveness and performance is
influenced by organizational culture (Nica & Potcovaru, 2017). Cultural diversity should
be involved in the organization’s culture to attain good business performance results
(Jalal, 2017). Valuing multiculturalism within an organization is a necessity as it is a
great way for enhancing business performance (Jalal, 2017). Hierarchy organizational
culture promotes knowledge governance in organizations to provide opportunities for
employees to share and enhance positive behavior at the workplace (Abbasi & Dastgeer,
2017).
Strong organizational culture is an indispensable condition for the survival and
development of any organization because it allows appropriate strategies and a good
decision-making process to be implemented (Nica & Potcovaru, 2017). The long-term
profitability and employee satisfaction must be aligned strategically with the leadership
actions. For underdeveloped organizational culture evaluations to be effective, they
should be tied to strategies designed to develop the culture (Reis, Paiva, & Sousa, 2018).
Currently, new costly techniques and growing demands for improved services put
European health care systems under increasing pressure (Lerer & Kimberly, 2017).
Public health sector spending has increased due to the introduction of different drugs
such as lifestyle and designer drugs, which continues to be a controversial political
issue (Lerer & Kimberly, 2017). Health care in European countries is fragmented with
individual countries pursuing different strategies and potential existing to reduce
inefficiencies and improve communications. Hospital administrations must aim to
strengthen the group human type of culture to produce positive overall quality
management, job satisfaction, profitability and commitment (Gabriel et al., 2017).
Systematic activities such as management technologies or many other approaches
can reshape organizational culture (Tang, 2017). An organization’s value system is a
very important factor that affects the relationship between its culture and performance
(Tang, 2017). According to Tang (2017), knowledge management influences
organizational culture and its effectiveness. Therefore, the better the organizational
culture, the higher the organizational effectiveness. Managers should consider using
knowledge management practices alongside with favorable culture incorporated to
improve organizational effectiveness (Abbas, Hayat, & Nisar, 2017).
NHS England became the first health care system in the world to implement a
Health care Safety Investigation Branch to improve patient safety (Macrae & Vincent,
2017). The branch investigates the most serious risks to patient safety across the health
care system for the purpose of learning and improvement. The Branch is entirely
independent of any regulatory or oversight bodies and cannot be directly involved in
implementing improvements.
Health care providers must adopt new ways to meet the diverse needs of
employees and patients (Borkowski, 2015). A few of these ways as discussed by
Borkowski are: Managers must possess the skills to communicate effectively with
diverse groups of people and understand workplace problems so that they can be
proactive and minimize negative outcomes; and, “Employees don’t leave organizations;
they leave managers (p. 4)!” Health care providers are changing their traditional
organizational structure and moving toward a multidisciplinary team-managed
environment.
The implementation of change in an organization relies on the organization's
culture, leadership and communication styles (Hansen, 2018). These changes can force
health care workers into new roles with new responsibilities and cause disruptions in the
workplace (Borkowski, 2015). The effect of change can lead to new beliefs and practices
that may conflict with those previously held (Hansen, 2018). The implementation phase
will require communication, engagement, and access to the appropriate resources
(Hansen, 2018). Characteristics such as planning, flexibility and preparation are
organizational cultures that may be approached differently from different leadership
perspectives. Depending on the type of change, a leader’s approach of the organization’s
culture may help to enable or disable the organizational change. Depending on existing
dimensions of an organization’s culture, business performance levels of an organization
can improve by selecting the appropriate quality improvement programs (Tomic et al.,
2017).
During organizational transition among practitioners who work in rural area
hospitals with integrated delivery systems, factors such as meaningfulness of work,
amount of work, job uncertainty, and employee attitudes towards organizational change
are strongly associated with job satisfaction/dissatisfaction (Waddimba, Scribani, Krupa,
May, & Jenkins, 2016). Peer support networks and coaching are efforts that can be used
to improve the quality of work life and reduce the widespread of dissatisfaction among
practitioners (Waddimba et al., 2016). Training programs for employees could better
manage diversity during and after a merger and acquisition (Shaban, 2016). Managers
should understand and promote the cultural differences by finding effective ways to
capitalize on employee backgrounds, perspectives and diverse skills (Shaban, 2016).
Health care organizations must reduce the profusion of behavior control and increase
levels of input and output controls in the management of people (Cogin, Ng & Lee,
2016). Human Resource can be used as a vehicle to address the strategic challenges
required to build and engaged workforce (Cogin et al., 2016). Currently, there is a need
for public health policymakers and health system researchers to conduct further research
on organizational culture and change within health systems (Mbau & Gilson, 2018).
The Nasurdin, Ahmad, and Ling's human resource model of service-oriented
organizational citizenship behaviors in health care are organizational behaviors that are
voluntarily performed by employees that go beyond their call of duty. A public health
care system's human resource management practices are instrumental in establishing the
tone of the employee-employer relationship (Nasurdin et al., 2015). A relational
employment relationship can be nurtured through high-performance human resource
management practices that, in turn, can lead to internalization of organizational values
and goals. Customer satisfaction and loyalty are enhanced when employees are
proactively involved in service delivery. Carmeli, Brammer, Gomes, and Tarba (2017)
suggested that based on the social identity theory, that an ethic of care is directly and
indirectly related to employees' satisfaction with organizational sustainability which can
drive employee involvement in sustainability-related behaviors. In the context of
networks, there is a need for a shift from bureaucratic, vertical, rule-based models of
management towards a more flexible cross-boundary, influence-based leadership style
(Brown et al., 2016). Employee assessments of attitudes and behaviors will be useful
when used in a system that uses principles, implementation approaches and management
commitment as part of a more extensive HR predictive analytics (HRPA) approach
(Shah, Irani, & Sharif, 2017).
Monetary Compensation
Monetary compensation is all forms of benefits and payment at a workplace such
as a wage or salary increases or unfulfilled expectations of wage or salary increases or
decreases (Alshmemri et al., 2017). Compensation of employees is one of the most
critical issues of all turnover causes (Das et al., 2017). Although financial incentives play
a key role in enhancing outcomes, they need to be considered as only one strategy within
an incentives package (Misfeldt, et al., 2014). In reviewing the empirical literature,
scholars such as Echoles, (2016): Alshmemri, Shahwan-Akil and Maude (2016): and
Yeboah and Abdulai (2016): Ray, (2016) and Yeboah and Abdukai, 2016 all agreed that
working conditions, rewards, and recognition, commission, monetary compensation, long
working hours, career development, culture, employee advancement opportunities,
scheduling, diversity and salary influenced employee motivation post-merger and
acquisition. A well-managed organization need never be bound to the same practices that
are not based on individual performance and outcomes (Kuppuswamy et al., 2017).
Employee motivation and satisfaction is positively associated with work
meaningfulness (Hussain & Thau, 2017). Consequently, organizations try to enhance
well-being by engaging in communication highlighting the importance and value of
intrinsically fulfilling work. This emphasis can dissuade employees from communicating
their concerns about extrinsic rewards such as monetary compensation. Money is one of
the most important motivational factors for employees (Kuppuswamy et al., 2017).
Employees, who stand to benefit the most from improving their material
prospects, are most likely to refrain from making compensation demands as they feel
vulnerable to potential job-related risks from norm deviation (Hussain & Thau, 2017).
Employee self-censorship on compensation matters may be an unintended consequence
of organizational emphasis on work meaning (Hussain & Thau, 2017). In society, money
is a source of status and prestige (Kuppuswamy et al., 2017). It also satisfies
physiological and security needs. Satisfaction of pay is caused by sentiments regarding
the equity of a person's pay (Das et al., 2017). Employees who perceive high pay equity
show greater job satisfaction than employees who perceives their pay to be less than
another's. This perception may result in several unwanted employee behaviors such as
absenteeism, grievances, strikes, and turnover. Organizations that make wages and
salaries competitive within their industry will attract and hold people (Kuppuswamy et
al., 2017). Management should ensure that salary and wages within the organization
match or nearly match individual workings in the same category and in the surrounding
areas. Organizations can then retain a sizeable number of its high performing employees
in the face of unabated economic woes (Das et al., 2017).
A study conducted by Onyango (2016) found that nurses were dissatisfied with
shift schedules, exposure to medical risk, job security, being short staffed and that their
salaries do not measure up to qualifications. Nurses also indicated that they intended to
leave the organization because wages were inadequate and they would go to work in
government facilities because benefits, pay, job security, and opportunities for growth are
better. Money may significantly influence retention in an unstable economic
environment (Das et al., 2017). Organizations must develop plans and establish clear
policies to address work environment, staff retention, and internal motivating factors
(Onyango, 2016). Organizations can properly align retention practices with the needs and
values of employees (Das et al., 2017). Flexible works arrangements should be
introduced for employees so that they can have personal time offs for rejuvenating
themselves. Professions with the greatest training requirements such as physicians and
registered nurses will see growth in wages (Parente, Feldman, Spetz, Dowd, & Baggett,
2017).
Summary
This chapter discussed the challenges faced by public health care providers in
reference to contemporary practices, outcomes and organizational behaviors in public
health care systems, particularly the health care system of NHS. According to the
empirical literature, factors such as opportunities for growth, work environment,
monetary compensation, work hours, organizational culture employee identity, language,
and branding and job security all play a vital role in employee motivation post-merger.
The culture of merged organizations was lacking because the culture for each merged
organization has not been formed under the new system.
Globally, public health care organizations promoted the transformation of health
care systems by using consolidated and integrated approaches. Citizens across
socioeconomic groups in 29 countries were motivated to support state-funded health care.
Evidence of the impact of the growing body of work on public involvement in the health
care policy process remains scarce. The United Kingdom implemented the patient and
public involvement initiative for holding policy-makers and health-care provider
organizations accountable for planning and delivering health services.
Employers must adapt to a variety of cultural and technological changes if they
want to retain and attract talented employees, improve employee performance and
maintain a competitive advantage. Mergers and Acquisitions can create uncertainty and
stress and in turn, affect job satisfaction, organizational commitment and intent to leave
due to their importance to the organization and the difficulty of their possible
replacement. The next chapter will provide more details about the methodology used for
the study.
Chapter 3: Research Methodology
Introduction
The purpose of this correlational study was to examine the statistical relationship
between growth opportunities, organizational culture, monetary compensation and
employee motivation. This chapter will discuss the research methodology used for the
study. The contents of this chapter consist of the hypothesis, population and sample size,
reliability and validity, ethical assurance and a summary.
The study examined the following research hypothesis: There is a correlation
between the independent variables (growth opportunities, organizational culture, and
monetary compensation) and the dependent variable (employee motivation). Variables
have multiple values that are observable. According to Miner (2015), these variables are
derived from constructs and, in essence, are an operation of constructs created to permit
the testing of hypotheses. The questionnaire items were statements of relationships
among the constructs. The questions in the questionnaire were not refuted or confirmed,
only the hypotheses. The hypotheses tested the following: Does MHT help explain
internal structural issues and inefficiencies in practices and outcomes in public health
care systems? Does the SIT help explain internal structural issues and inefficiencies in
practices and outcomes in public health care systems?
According to Johnston (2017), existing data can be used in addressing the
research hypothesis. I received approval from Walden’s Institution Review Board to
obtain the secondary dataset from the NHS Survey Coordination Centre. The IRB
approval number is 07-17-18-0481939. The NHS Survey Coordination Centre oversaw
the data collection process. It provided individual organizations with instructions for the
survey data collection. The instructions included key task; a summary of the minimum
survey requirements; approved survey contractors; survey timetable with deadline dates
and steps of survey implementation; confidentiality concerns; online surveys (e-mail
deliverability); the questionnaire; cover letters and email reminders; preparation of staff
lists; and, distribution and receipt of questionnaires and prompting nonrespondents (NHS,
2017).
A Pearson Biserial Correlation Coefficient statistical t test was used to test the
hypotheses. The data were examined using a descriptive frequency statistical test to
show a descriptive analysis. The tests were run using the software, Statistical Package
for the Social Sciences (SPSS), version 24, to confirm the results.
In the social science research process, there are three possible methods:
quantitative, qualitative and mixed methods (Creswell, 2014). Secondary data were used
for the study. Therefore, a quantitative approach was most appropriate. With the
quantitative method, I was able to test the hypotheses, relate the variables to the
hypotheses, and measure information using instruments and procedures. A qualitative or
mixed methods approach was not used for this study because it could not support or
refute the hypotheses nor use analytical instruments to collect and analyze the secondary
data.
The research hypotheses under study were: there is a correlation between the
independent variables growth opportunities, organizational culture, monetary
compensation and dependent variable, employee motivation. Growth opportunities are
the real opportunities for a person to experience personal growth, learn the new skill,
undergo training in new techniques, and gain new professional knowledge (Alshmemri et
al., 2017). The results of the study will determine whether growth opportunities
significantly correlate with employee motivation.
Organizational culture is best improved by organizational learning for change
(Serrat, 2017). Organizational culture is the pattern of underlying assumptions that a
given group has invented, discovered, or developed in learning to cope with its problems
of external adaptation and internal integration and have worked well enough to be
considered valid to be taught to new members to perceive, think, and feel in relation to
those problems (Schein, 1984). Employees must share the values and beliefs of the
company.
Money is not adversely associated with cooperation, although the salience of
money is associated with increases in self-serving behaviors (Beus & Whitman, 2017).
Monetary compensation is all forms of payment at a workplace such as a wage or salary
increases or unfulfilled expectations of wage or salary increases or decreases (Alshmemri
et al., 2017). Financial incentives need to be considered as only one strategy within an
incentives package (Misfeldt et al., 2014).
The online survey was the best instrument to gather the data from the participants
using a questionnaire composed of closed-end questions (Abbott & McKinney, 2013).
According to Creswell (2009), using an online survey, researchers can create their
surveys quickly using custom templates and post them on websites or e-mail them for
participants to complete (p. 149). Surveys are arguably the most used tool for social
scientists and a variety of others looking for information about people's attitudes,
behaviors, and experiences (Abbott & McKinney, 2013). Surveys also lend themselves
to a statistical organization. A cross-sectional design was used to collect the data at one
point in time (Anderson et al., 2017). The survey instrument translated unobservable
content into empirical referents to observe patterns across a group of respondents (Abbott
& McKinney, p. 206, 2013).
Research Hypotheses
Research Null Hypotheses—Quantitative: There is a correlation between the
independent variables growth opportunities, organizational culture, monetary
compensation and dependent variable, employee motivation. A Point-Biserial
Correlational Coefficient model statistical t test was used to test each hypothesis. The
significance level was .05 or less to reject the null hypotheses. Employee motivation
(dependent variable) was operational through the following question in the questionnaire:
I look forward to going to work.
Hypotheses
Research Null Hypothesis 1: There is a correlation between growth opportunities and
employee motivation. Growth opportunities (independent variable) were operational
through the following two questions in the questionnaire: my training, learning and
development have helped me to do my job more effectively and my training, learning and
development has helped me to stay up-to-date with professional requirements.
Hº: There is no correlation between growth opportunities and employee
motivation.
Hª: There is a correlation between growth opportunities and employee
motivation.
Research Null Hypothesis 2: There is a correlation between organizational culture and
employee motivation? Organizational culture (independent variable) was operational
using the following questions in the questionnaire: senior managers here try to involve
staff in important decisions and communication between senior management and staff is
effective.
Hº: There is no correlation between organizational culture and employee
motivation.
Hª: There is a correlation between organizational culture and employee
motivation.
Research Null Hypothesis 3: There is a correlation between monetary compensation
and employee motivation? Monetary compensation (independent variable) was
operational through the following questions in the questionnaire: my level of pay and the
recognition I get for good work.
Hº: There is no correlation between monetary compensation and employee
motivation.
Hª: There is a correlation between monetary compensation and employee
motivation.
Population and Sample Size
The population in which the sample was drawn was from two NHS England
Acute Trust Hospital sites in the United Kingdom (Suburban Hospital and Metropolitan
University Hospital). The secondary data were collected from a random sampling, from a
population of 4850 (Suburban) and 2669 (Metropolitan) health care workers from the two
English hospitals on a five-point Likert scale questionnaire. A Cronbach's Alpha
reliability test of the items in the questionnaire was applied using SPSS (statistical
package for social science) version 24.0 (David & Pandey, 2015). The questionnaire was
well suited for the measurement of job satisfaction, work experience, environment, and
engagement (Stahl, Schirmer, & Kaiser, 2017). It was a useful tool that supported
employers and human resource managers in shaping and motivating an efficient work
environment (Stahl et l., 2017). The type of power analysis used for the study was post
hoc, two tails, with an effect size of .50, error probability of .05, with a total sample size
of 3,033 using Point-Biserial Correlation Coefficient model statistical t test. The
noncentrality parameter was 31.796; Df was 3031, Critical t was 1.96, and power (1-β err
probability) 1.00. The sample size was calculated using G-power 3.1.
Reliability and Validity
The Care Quality Commission and its predecessor, the Health Care Commission,
owned the NHS Staff Survey from 2003 to 2009. The Department of Health granted
ownership to NHS England in 2013. The results of the questionnaire were used by NHS
England to support national assessments of quality and safety and to inform local
improvements in staff experience and wellbeing. Standard items from previously used
questionnaires were reliable and valid (Abbott & McKinney, 2013, pp. 212, 213). The
reliability and validity were in the construction of the questionnaire’s items (Abbott &
McKinney, 2013, p. 223). The notion of credibility required that the subjects who
provided the data believed that the interpretation was credible from their perspective
because likelihood confirms validity (Newby, 2013, p. 121). The primary investigator
had a reputation for excellence in research integrity (Johnston, 2017). NHS collects staff
surveys yearly to examine staff views and experiences of their work performance in their
local health care organization and to provide information for deriving national and local
performance indicators (NHS, 2017). Each year, the survey builds a picture of staff
experience to compare and monitor change over time and to identify variations between
different staff groups. All NHS Trusts were required to participate in the survey.
Cronbach's alpha was used to estimate the scale quality. The Cronbach's alpha is
a commonly reported estimate to assess scale quality in health psychology and related
disciplines (Crutzen & Peters, 2017). Validity and reliability were not two independent
elements of scale quality. Although validity was a key element of scale quality,
reliability was just as crucial as validity. Validity referred to the degree to which
evidence and theory supported the interpretation of the scale scores. Each study,
including studies with commonly used scales, needed the attention of assessing validity.
Evidence from previous studies was used to substantiate scale choices. Reliability was
the consistency of scale scores when a construct was assessed in multiple ways. The
broadness of the operational of each item affected scale quality estimates, meaning that
very high estimates were indicative of low validity. The minimum reliability standards
were .70 and .80 (Gugiu & Gugiu, 2018). These standards were used to determine
whether the decision criterion was satisfied by the observed reliability coefficient.
Assumption violations such as unidimensionality and uncorrelated errors of all
items were mitigated by identifying and excluding questions from the calculation of the
factor score for further analyses (Brown, et al., 2016). Validity was assessed by
undertaking a scale reliability analysis in SPSS on the survey data questions used in the
study to compute Cronbach’s alpha. This approach provided information about the
structure and factors as designed. Therefore, it was more appropriate than using an
exploratory analysis of the questions which investigates alternative factor structures.
Items that had a factor loading less than .04 were considered for exclusion from the list of
items.
Ethical Assurances
Hemminki (2014) declared that the key to regulating health research is the review
by the research ethics committees. The National Health Service Health Research
Authority approves research. The Research Ethics Service Committee determined that
this was considered an analysis study and not a research study. In the case of this study, a
different review was used by the Ethics Service Committee because the study is an
analysis of a large aggregate data set provided by NHS (Dove et al., 2016). The NHS
research ethics committees monitor publication and outcome reporting bias (Begum &
Kolstoe, 2015). They hold complete records of all human research that is subject to
particular legal regulation or conducted within the NHS. By doing so, this places them in
a stronger position than individual sponsors or research funders when it comes to auditing
or monitoring and reporting bias.
Summary This chapter discussed the
methodology and design of the method of inquiry. The quantitative study used secondary
data from the National Health Services England's
(NHS) 2016 Staff Survey. Existing data was used in addressing the research hypotheses.
Statistical Package for the Social Sciences (SPSS) version 21, Software was used as the
engine to analyze the data using a Pearson Biserial Correlation Coefficient model
statistical t test. This study investigated whether there was a correlation between the
independent variables growth opportunities, organizational culture and monetary
compensation and the dependent variable, employee motivation.
The population and sample were from two NHS England Acute Hospital Trust
sites located in the United Kingdom. The population consisted of two NHS England
Foundation Trust sites: a General Hospital-Acute Trust located in a metropolitan area and
a University Hospital-Acute Trust located in a suburban area of England. The General
Hospital-Acute Trust located in the metropolitan area was built in 1970. The public
hospital replaced three other public hospitals that were built in the late 1800s. The
University Hospital-Acute Trust located in the suburban area of England was founded in
1828. In 1898 the university hospital was acquired as City Hospital.
The random sample consisted of 3,033 public health care workers respondents
from the two English hospitals. The primary investigator had a reputation for excellence
in research integrity. NHS collects staff surveys yearly to examine staff views and
experiences of the work they perform in their local health care organization and to
provide information for deriving national and local performance indicators. Most of the
limitations of using secondary data were avoided by ensuring a match between the
research hypotheses and the existing data. Cronbach's alpha was used to estimate the
scale quality. Assumptions were checked to ensure reliability and validity. The items in
the questionnaire were not refuted or confirmed, only the hypotheses. The hypotheses
tested the following: Does motivation-hygiene theory help explain structural issues and
inefficiencies in practices and outcomes in public health care systems? Does the social
identity theory help explain structural issues and inefficiencies in practices and outcomes
in public health care systems? For ethical assurances, the National Health Service Health
Research Authority approved the study. The next chapter is a review of the study’s
results.
Chapter 4 Results
Introduction
The purpose of this correlational study was to examine the statistical relationship
between growth opportunities, organizational culture, monetary compensation and
employee motivation. Previous research on internal organizational practices and
outcomes stated that the performance of public sector employees is critical to the delivery
of services (Knies et al. (2017). Likewise, Van Dooren et al. (2015) found that
performance management plays a pivotal role in public policy and reform initiatives.
Knies et al ‘s (2017) results align with Van Dooren et al. (2015) in the ways that are
consistent with Knies et al. (2017) and Rua and Correia’s (2017) argument that in order
for organizations to survive, they must have the ability to respond to the needs in the
practices and outcomes of public health care systems.
This chapter is a discussion of the data collection process and summarizes the
results of the research hypotheses constructed using hypothetical analyses. The research
hypotheses under examination were: There is a correlation between independent
variables: growth opportunities, organizational culture, and monetary compensation and
dependent variable, employee motivation. An examination of the variables (growth
opportunities, organizational culture, monetary compensation and employee motivation)
determined if the null hypothesis was accepted or rejected. A data-driven approach was
used to glance through variables in a particular dataset to decide if the research
hypotheses and theories could be answered by the available data. The dataset contained
variables that were modified to operational variables for the examination plan based on
the best available data. Operational definitions were generated of the dependent and
independent variables that were considered in the examination.
Data Collection
The timeframe for the data collection was between late September and early
December 2016. All full-time and part-time employees who were directly employed on
or before September 1, 2016 by an NHS organization were eligible to respond. The
recruitment was done by an independent survey contractor with questionnaires being sent
to random employees in each trust (Powell, Dawson, Topakas, Durose & Fewtrell, 2014).
The Coordination Centre (Picker Institute Europe) oversees the independent survey
contractor on behalf of NHS England.
The 2016 questionnaire marks the fourteenth year the staff questionnaire has been
conducted. The response rates for the organizations examined were Suburban University
Area Acute Trust, 43% from a total population of 4850 and 40% from a total population
of 2669 in the Metropolitan Area Acute Trust Hospital. The data were collected through
random sampling for a total of 3,033 health care workers from the two English hospitals
on the five-point Likert scale questionnaire. The sample size enabled the researcher to
make an unequivocal judgment that the statistical result was correct to a chosen degree of
error (‘type I error’) and had sufficient power (‘1-type II error’) to detect a specified
meaningful effect that was suitable for testing the hypotheses. The type of power
analysis used for the study was post hoc, two tails with an effect size of .50, error
probability of .05 with a total sample size of 3,033 using Point-Biserial Correlational
Coefficient model statistical t-test. The non-centrality parameter was be 31.796, Df is
3031, Critical t will be 1.96, and power (1-β err probability) 1.00. The sample size was
calculated using G-power 3.1.
The Cronbach’s alpha analysis performed on all items of the instrument showed
strong covariance between the set of items. The result of the Cronbach’s alpha analysis
was .772, and based on standard items the Cronbach’s alpha was .775. The following
variables had zero variance and were removed from the scale: In the last three months
have you ever come to work despite not feeling well enough to perform your duties?,
Have you had any training, learning or development in the last 12 months? (Please do not
include mandatory training), In the last 12 months, have you had an appraisal, annual
review, development review, or Knowledge and Skills Framework (KSF) development
review? Were any training, learning or development needs identified? Is patient / service
user experience / feedback collected within your directorate / department? For example,
Friends and Family Test, patient surveys etc. Reliability coefficients classify as .7-.8 as
good and .8 or above as excellent. Table 1 shows the validity of the 7 items used for the
study. Table 2 indicates the items’ reliability. The indicators for Cronbach's alpha in each
domain were measured with a covariance greater than .3 which indicates a significant
correlation between questions on a domain (Brown et al., 2016).
Table 4.1 Questionnaire Items Validity
Items Means Minimum Maximum Standard
Deviation
No No. of
Items
I look forward to going to work. 3.56 1 5 .920 1870 7
The recognition I get for work. 3.37 1 5 1.052 1870 7
My level of pay. 3.06 1 5 1.105 1870 7
Communication between senior
management and
3.10 1 5 1.106 1870 7
Senior managers here try
to involve staff in
important decisions.
2.97 1 5 1.135 1870 7
My training, learning and
development has helped me to do
my job more effectively.
3.94 1 5 .824 1870 7
My training, learning and
development has helped me to
stay up-to-date with professional
requirements
4.18 1 5 1.169 1870 7
Table 4.2 Internal Reliability Estimations
Covariance and
Correlations
Mean Minimum Maximum Range Max/
Min
Cronbach’s
Alpha
Reliability
Inter-Item
Covariance
.360 .158 1.028 .873 6.525 .772 Good
Inter-Item
Correlation
.330 .147 .819 .673 5.589 .775 Good
Methodology: Theoretical Framework
Herzberg’s 1959 motivation-hygiene and Tajfel & Turner’s 1986 social identity
theories can be expressed between the independent and dependent variables as follows:
*Cronbach’s Alpha based on standardized items
.
DV
Motivation-Hygiene Theory
The motivation-hygiene theory generalize specific relationships between the
independent and dependent variables that may influence internal structural issues that
affect organizational practices and outcomes in public health care systems. Figures 1, 2
and 3 below depict factors found in the literature review that correlated with the
motivation-hygiene and social identity theories that also correlate with this study’s
variables.
Employee
Motivation
Growth Opportunities
IV
Organizational
Culture
IV
Monetary Compensation
IV
Figure 4.1 Motivator Factors
DV - Employee
Motivation
IV -Growth
Opportunities
training &
development
level of
responsibility
incentives
personal
achievement
Figure 1 shows the relationship to employee motivation in the center circle and
how training and development, level of responsibility, incentives, and personal
achievement may be associated with growth opportunities based on the literature review.
According to Hur (2017), Herzberg’s motivation-hygiene theory can be promising if it is
applied to public employees. Table 3 and Table 4 describe the frequency and correlation
between employee motivations by operational variable I look forward to going to work.
The operational variables used for growth opportunities were my training, learning and
development has helped me to do my job more effectively and my training, learning and
development has helped me to stay up-to-date with professional requirements.
The results showed a significant correlation between employee motivation and
growth opportunities in both, the Metropolitan Area Acute Trust Hospital and the
Suburban University Area Acute Trust Hospital. The operational variable my training,
learning and development has helped me to do my job more effectively in both, the
Metropolitan Area Acute Trust Hospital and the Suburban University Area Acute Trust
Hospital had significances levels of .000 < .05. The frequency distribution analysis
showed that of 707 health care workers in the Metropolitan Area Acute Trust Hospital,
401 (56.7%) of the health care workers agreed that their training, learning and
development has helped them to do their job more effectively. In contrast, 766 (61.1%)
of 1,254 health care workers in the Suburban University Area Acute Trust Hospital
agreed that their training, learning and development has helped them to do their job more
effectively. Interestingly, the Suburban University Area Acute Trust Hospital is a
University Hospital known for teaching. Future research is needed to determine if
employees who work for a Suburban University Area Acute Trust Hospital is provided
with more training and learning opportunities than employees who work for a
Metropolitan Area Acute Trust Hospital since the Suburban University Area Acute
Trust Hospital is known for teaching.
The operational variable “my training, learning and development has helped me to
stay up-to-date with professional requirements” also showed significances levels of
.000 < .05 in both, the Metropolitan Area Acute Trust Hospital and the Suburban
University Area Acute Trust Hospital. Of the 703 health care workers in the
Metropolitan Area Acute Trust Hospital, 403 (57.3%) agreed that training, learning and
development has helped them to stay up-to-date with professional requirements. In
comparison, of 1247 health care workers in the Suburban University Area Acute Trust
Hospital, 773 (62%) agreed that their training, learning and development has helped
them to stay up-to-date with professional requirements.
Pearson Correlation 1
Research Null Hypothesis: 1
Hₒ: There is no correlation between growth opportunities and employee
motivation.
Hₐ: There is a correlation between growth opportunities and employee
motivation.
The null hypothesis is rejected at the 0.05 level of significance. There is
sufficient evidence to conclude that growth opportunities significantly correlate with
employee motivation through operational variables, with a significance result of .000
< .05. Therefore, we can accept the alternative hypothesis that growth opportunities are
correlated with employee motivation in the Metropolitan Area Acute Trust Hospital and
in the Suburban University Area Acute Trust Hospital.
Table 3 depicts the correlation and frequency distribution results between
employee motivation and growth opportunities in a Metropolitan Area Acute Trust
Hospital. Employee motivation= I look forward to going to work. Growth opportunities
1=my training, learning and development has helped me to do my job more effectively.
Growth opportunities 2=my training, learning and development has helped me to stay
up-to-date with professional requirements.
Table 4.3 Correlation and Frequency Distribution for Employee Motivation and Growth
Opportunities in a Metropolitan Area Acute Trust Hospital.
Variable Frequency Correlation I look
forwar
d to
going to
work
My
training,
learning
and
developme
nt has
helped me
to do my
job more
effectively
My training,
learning and
development
has helped me
to stay up-to
date with
professional
requirements
Employee
Motivation
435
(41.8%) Often
Pearson
Correlation
Sig. (2-tailed)
N
1
1040
Growth
Opportunitie
s 1
401
(56.7%)
Agreed
Pearson
Correlation
Sig. (2-tailed)
N
707
.306**
.000
Growth
Opportunitie
s 2
403
(57.3%)
Agreed
Pearson
Correlation
Sig. (2-Tailed)
N
703
.104**
.006
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always.
Metropolitan Area Acute Trust Hospital.
Table 4 depicts correlation and frequency distribution results between employee
motivation and growth opportunities in the Suburban University Area Acute Trust
Hospital. Employee motivation= I look forward to going to work. Growth opportunities
1=my training, learning and development has helped me to do my job more effectively.
Growth opportunities 2=my training, learning and development has helped me to stay up-
to-date with professional requirements.
Table 4.4 Frequency Distributions for Employee Motivation and Growth Opportunities
Suburban Area Acute Trust Hospital.
Variable Frequency Correlation I look
forward
to going
to work
My training,
learning and
development
has helped
me to do my
job more
effectively
My training,
learning and
development has
helped me to
stay up-to date
with
professional
requirements
Employee
Motivation
754
(38.7%)
Often
Pearson
Correlation
Sig. (2-tailed)
N
1
1946
Growth
Opportunit
ies 1
766
(61.1%)
Agreed
Pearson
Correlation
Sig. (2-tailed)
N
1254
.224**
.000
Growth
Opportunit
ies 2
773
(62%)
Agreed
Pearson
Correlation
Sig. (2-Tailed)
N
1247
.166**
.000
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always.
Suburban Area Acute Trust Hospital.
Social Identity Theory
Figure 2 shows factors (social categorization, social identification, social
comparison and organizational practices) found in the literature review in the outer circle
that correlate with the social identity theory. The variables locate in the center of Figure
2 were tested to see if there was a correlation between employee motivation and
organizational culture. A positive correlation can provide organizations with strategies
and techniques to address culture and employee motivation utilizing the factors found in
the outer circle of Figure 2 that define the social identify theory (Ghafournia, 2015).
The results showed a significant correlation between employee motivation and
organizational culture in both, the Metropolitan Area Acute Trust Hospital and the
Suburban University Area Acute Trust Hospital. The operational variable “senior
managers here try to involve staff in important decisions” had a significance level of .000
< .05 in both, the Metropolitan Area Acute Trust Hospital and the Suburban University
Area Acute Trust Hospital. The frequency distribution analysis showed that of 1,031
health care workers in the Metropolitan Area Acute Trust Hospital, 247 (23.9%) of the
health care workers agreed that senior managers try to involve staff in important
decisions. In contrast, 466 (24.3%) of 1,917 health care workers in the Suburban
University Area Acute Trust Hospital agreed that senior managers try to involve staff in
important decisions.
The operational variable “communication between senior management and staff is
effective” also showed significances levels of .000 < .05 in both, the Metropolitan Area
Acute Trust Hospital and the Suburban University Area Acute Trust Hospital. Of the
1,032 health care workers in the Metropolitan Area Acute Trust Hospital, 287
(27.8%) agreed that communication between senior management and staff is effective.
In comparison, of 1,917 health care workers in the Suburban University Area Acute Trust
Hospital, 528 (27.5%) agreed that communication between senior management
and staff is effective.
Pearson Correlation 2
Research Null Hypothesis: 2
Hₒ: There is no correlation between organizational culture and employee
motivation.
Hₐ: There is a correlation between organizational culture and employee
motivation.
The null hypothesis is rejected at the 0.05 level of significance. There is
sufficient evidence to conclude that organizational culture significantly correlate with
employee motivation through operational variables, with a significance result of .000
< .05. Therefore, we can accept the alternative hypothesis and say that there is a
correlation between organizational culture and employee motivation in both the
Metropolitan Area Acute Trust Hospital and in the Suburban University Area Acute
Trust Hospital.
Tables 5 and 6 represent the correlation and frequency distribution between
employee motivation and organizational culture. In the tables, the variables employee
Figure 4.2 Social Identity
DV - Employee
Motivation
IV -Organi zational
Culture
social
categorization
social
identification
social
comparison
organizational
practices
motivation and organizational culture, show a positive correlation with significance levels
of .000< .05 in both, a Metropolitan Area Acute Trust Hospital and a Suburban
University Area Acute Trust Hospital.
Table 5 describes the correlation and frequency distribution results between
employee motivation and organizational culture. Employee motivation= I look forward to
going to work. Organizational Culture 1= senior managers here try to involve staff in
important decisions. Organization Culture 2= Communication between senior
management and staff is effective.
Table 4.5 Correlation and Frequency Distributions for Employee Motivation and
Organizational Culture in a Metropolitan Area Acute Trust Hospital.
Variable Frequency Correlation I look
forward
to going
to work
Senior
managers
here try to
involve staff
in
important
decisions
Communicati
on between
senior
management
and staff is
effective
Employee
Motivation
435
(41%) Often
Pearson
Correlation Sig.
(2-tailed)
N
1
1040
Organizational
Culture 1
247
(23.9%) Agreed
Pearson
Correlation Sig.
(2-tailed)
N
1031
.381**
.000
Organizational
Culture 2
287
(27.8%) Agreed
Pearson
Correlation Sig.
(2-Tailed) N
1032
.397**
.000
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always.
Metropolitan Area Acute Hospital.
Table 6: Correlation and frequency distribution results between employee
motivation and organizational culture. Employee motivation= I look forward to going to
work. Organizational culture 1= senior managers here try to involve staff in important
decisions. Organizational culture 2= Communication between senior management and
staff is effective.
Table 4.6 Correlation and Frequency Distributions for Employee Motivation and
Organizational Culture in a Suburban University Area Acute Hospital.
Variable Frequency Correlation I look
forward to
going to
work
Senior
managers
here try to
involve staff
in
important
decisions
Communicati
on between
senior
management
and staff is
effective
Employee
Motivation
754
(38.7%) Often
Pearson
Correlation Sig.
(2-tailed)
N
1
1946
Organization
al Culture 1
466
(24.3%) Agreed
Pearson
Correlation Sig.
(2-tailed)
N
1917
.343**
.000
Organization
al Culture 2
528
(27.5%) Agreed
Pearson
Correlation Sig.
(2-Tailed) N
1917
.328**
.000
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always. Suburban
University Area Acute Hospital.
Figure 3 below shows hygiene factors and the relationship with employee
motivation in the center circle and how job security, benefits, salary and working
environment contribute to monetary compensation. Herzberg’s motivation-hygiene
theory can be promising if it is applied to public employees (Hur, 2017). Table 7 and
Table 8 indicate the significance of the correlation between employee motivation and
monetary compensation in both, the Metropolitan Area Acute Trust Hospital and the
Suburban University Area Acute Trust Hospital.
The operational variable “my level of pay” and “the recognition I get for good
work” had a significance level of .000 < .05 in both, the Metropolitan Area acute Trust
Hospital and the Suburban University Area Acute Trust Hospital. For “my level of pay”,
the frequency distribution analysis showed that of 1,022 health care workers in the
Metropolitan Area Acute Trust Hospital, 376 (36.7%) of the health care workers were
satisfied with their level of pay. In contrast, 600 (31%) of 1,937 health care workers in
the Suburban University Area Acute Trust Hospital were satisfied with their level of pay.
The operational variable “the recognition I get for good work” also showed significances
levels of .000 < .05 in both, the Metropolitan Area Acute Trust Hospital and the
Suburban University Area Acute Trust Hospital. Of the 1,032 health care workers in the
Metropolitan Area Acute Trust Hospital, 447 (43.3%) were satisfied with the recognition
they get for good work. In comparison, of 1,950 health care workers in the Suburban
Area Acute Trust Hospital, 724 (37.1%) were satisfied with the recognition they get for
good work.
Pearson Correlation 3
Research Null Hypothesis: 3
Hₒ: There is no correlation between monetary compensation and employee
motivation.
Hₐ: There is a correlation between monetary compensation and employee
motivation.
The null is rejected at the 0.05 level of significance, accepting the alternative
hypothesis. There is sufficient evidence to conclude that monetary compensation
significantly correlate with employee motivation through operational variables, with a
significance result of .000 < .05. Therefore, we can accept the alternative hypothesis that
monetary compensation is correlated with employee motivation in both the Metropolitan
Area Acute Trust Hospital and in the Suburban University Area Acute Trust Hospital.
Table 7: Correlation and Frequency distribution results between employee motivation and
monetary compensation. Employee motivation= I look forward to going to work and
monetary compensation 1=my level of pay and monetary compensation 2=The
recognition I get for good work.
Table 4.7 Correlation and Frequency Distributions for Employee Motivation and
Monetary Compensation in the Metropolitan Area Acute Hospital.
Variable Frequency Correlation I look forward
to going to work
My
level
of
pay
The
recognition I
get for good
work
Employee
Motivation
435
(41.8%) Often
Pearson Correlation
Sig. (2-tailed)
N
1
1040
Monetary
Compensatio
n 1
376
(36.7%) Agreed
Pearson Correlation
Sig. (2-tailed)
N
1022
.311*
*
.000
Monetary
Compensatio
n 2
447
(43.3%) Agreed
Pearson Correlation
Sig. (2-Tailed)
N
1032
.492**
.000
Figure 4.3 Hygiene Factors
DV - Employee
Motivation
IV -Monetary
Compensation
job security
benefits
salary
working
environment
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always.
Metropolitan Area Acute Hospital.
Table 8: Correlation and Frequency distribution results between employee
motivation and monetary compensation. Employee motivation= I look forward to going
to work. Monetary compensation 1=my level of pay and monetary compensation 2=The
recognition I get for good work.
Table 4.8 Correlation and Frequency Distributions for Employee Motivation and
Monetary Compensation in a Suburban University Area Acute Hospital.
Variable Frequency Correlation I look forward
to going to work
My level
of pay
The
recognition I
get for good
work
Employee
Motivation
754
(38.7%) Often
Pearson Correlation
Sig. (2-tailed)
N
1
1946
Monetary
Compensation 1
600
(31%)
Satisfied
Pearson Correlation
Sig. (2-tailed)
N
1937
.271** .
000
Monetary
Compensation 2
724
(37.1%)
Satisfied
Pearson Correlation
Sig. (2-Tailed)
N
1950
.450**
.000
** Correlation is significant at the 0.01 level (2-tailed). Frequency – never, rarely, sometimes, often and always. Suburban
University Area Acute Hospital.
Summary and Conclusion
This study examined the correlation between growth opportunities, organizational
culture and monetary compensation on employee motivation. As such, 3,033 health care
workers from two public Acute Trust Hospitals were sampled. A descriptive frequency
distribution test found that a significant correlation between employee motivation and
growth opportunities in both, the Metropolitan Area Acute Trust Hospital and Suburban
University Area Acute Trust Hospital. The operational variable my training, learning and
development has helped me to do my job more effectively in both, the Metropolitan Area
Acute Trust Hospital and Suburban University Area Acute Trust Hospital had
significances levels of .000 < .05. The frequency distribution analysis showed that of 707
health care workers in the Metropolitan Area Acute Trust Hospital, 401 (56.7%) of the
health care workers agreed that their training, learning and development has helped them
to do their job more effectively. In contrast, 766 (61.1%) of 1,254 health care workers in
the Suburban University Area Acute Trust Hospital agreed that their training, learning
and development has helped them to do their job more effectively.
The operational variable my training, learning and development has helped me to
stay up-to-date with professional requirements also showed significances levels of
.000 < .05 in both, the Metropolitan Area Acute Trust Hospital and Suburban
University Area Acute Trust Hospital. Of the 703 health care workers in the
Metropolitan Area Acute Trust Hospital, 403 (57.3%) agreed that training, learning and
development has helped them to stay up-to-date with professional requirements. In
comparison, of 1247 health care workers in the Suburban University Area Acute Trust
Hospital, 773 (62%) agreed that their training, learning and development has helped them
to stay up-to-date with professional requirements.
The results showed a significant correlation between employee motivation and
organizational culture in both, the Metropolitan Area Acute Trust Hospital and Suburban
University Area Acute Trust Hospital. The operational variable “senior managers here
try to involve staff in important decisions” had a significance level of .000 < .05 in both,
the Metropolitan Area Acute Trust Hospital and Suburban University Area Acute Trust
Hospital. The frequency distribution analysis showed that of 1,031 health care workers in
the Metropolitan Area Acute Trust Hospital, 247 (23.9%) of the health care workers
agreed that senior managers try to involve staff in important decisions. In contrast, 466
(24.3%) of 1,917 health care workers in the Suburban University Area Acute Trust
Hospital agreed that senior managers try to involve staff in important decisions.
The operational variable “communication between senior management and staff is
effective” also showed significances levels of .000 < .05 in both, the Metropolitan
Area Acute Trust Hospital and Suburban University Area Acute Trust Hospital. Of the
1,032 health care workers in the Metropolitan Area Acute Trust Hospital, 287 (27.8%)
agreed that communication between senior management and staff is effective. In
comparison, of 1,917 health care workers in the Suburban University Area Acute Trust
Hospital, 528 (27.5%) agreed that communication between senior management and staff
is effective.
The results showed a significant correlation between employee motivation and
monetary compensation in both, the Metropolitan Area Acute Trust Hospital and
Suburban University Area Acute Trust Hospital. The operational variable “my level of
pay” and “the recognition I get for good work” had a significance level of .000 < .05 in
both, the Metropolitan Area Acute Trust Hospital and Suburban University Area Acute
Trust Hospital. For “my level of pay”, the frequency distribution analysis showed that of
1,022 health care workers in the Metropolitan Area Acute Trust Hospital, 376
(36.7%) of the health care workers were satisfied with their level of pay. In contrast,
600 (31%) of 1,937 health care workers in the Suburban University Area Acute Trust
Hospital were satisfied with their level of pay.
The operational variable “the recognition I get for good work” also showed
significances levels of .000 < .05 in both, the Metropolitan Area Acute Trust Hospital and
Suburban University Area Acute Trust Hospital. Of the 1,032 health care workers in the
Metropolitan Area Acute Trust Hospital, 447 (43.3%) were satisfied with the recognition
they get for good work. In comparison, of 1,950 health care workers in the Suburban
University Area Acute Trust Hospital, 724 (37.1%) were satisfied with the recognition
they get for good work.
The Pearson Biserial Correlational Coefficient model statistical t test was used to
test each hypothesis at a .05 level of significance. The test consisted of continuous
variables to produce correlation coefficients for each pair of variables in the list. The
correlation test was appropriate for the study because it investigated the relationship
between the variables. According to Mertler and Reinhart (2016), a conclusion can be
made in a nonexperimental study that the independent and dependent variables are related
to each other because there is no manipulation or random assignment. Although more
research is needed to identify the demographics of respondents, findings suggest a need
to sensitize policy makers such as the Department of Health and Human Services and
health care administrators about the factors that influence employee motivation in
metamorphose conglomerated health care systems. The next chapter will discuss the key
findings, interpretation of the findings, recommendations and implications for social
change.
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
Globally, public concerns about health care systems propelled governments to
cope with the challenge of meeting the demands of health care systems (Klein, 1993;
Popescu & Predescu, 2016). Health care partnerships are pursuing comprehensive
strategies such as mergers and acquisitions as a source to transform health and well-being
in their communities (Siegel, Erickson, Milstein, & Pritchard, 2018). Research
conducted by Ghiasi et al. (2017) support mergers and acquisitions as a way to improve
quality of care, contain cost, and financial performance for health care organizations.
The most basic challenge in health care service environments of tension and division of
labor is the performance of employees (Platis, Reklitis & Zimeras, 2015). Health care
workers form the backbone of any health system (Okello & Gilson, 2015). Balancing the
work system and encouraging the active and adaptive role of workers are the key
principle for improving health care quality (Carayon, Wetterneck, Rivera-Rodriguez,
Hundt, Hoonakker, Holden, & Gurses, 2014). Health care organizations must have the
ability to respond to a growing number of needs in the practices and outcomes of public
health care systems in order to survive (Rua & Correia, 2017).
This study examined the correlation between growth opportunities, organizational
culture and monetary compensation on employee motivation. A Pearson Correlation test
was used to test the hypothesis of the variables. The instrument used to collect the data
was a consensus questionnaire. Permission was granted from the National Health Service
England’s (NHS) Survey Coordination Centre to use the 2016 archival dataset (NHS,
2017). The data collection instrument was a paper and online questionnaire containing a
set of core questions. A Cronbach’s alpha analysis run in SPSS showed a strong result of
.775 for the items of the instrument for validity and reliability. Sample sizes of 3,033
health care workers were from two Acute Hospital Trust sites in England, United
Kingdom. The sample size was calculated using G-power version 3.1. The data were
summarized using a descriptive statistical test to test the hypotheses. The use of
secondary data provides a viable option for researchers who may have limited resources
and time (Johnston, 2017).
Key findings from the descriptive frequency distribution test found significance
levels of .000 < .05 between growth opportunities, organizational culture, monetary
compensation and employee motivation in both, the Metropolitan Area Acute Trust
Hospital and the Suburban University Area Acute Trust Hospital. Therefore, we can say
that growth opportunities, organizational culture and monetary compensation are
correlated with employee motivation in the Metropolitan Area Acute Trust Hospital and
Suburban University Area Acute Trust Hospital.
Interpretation of the Findings in the Peer-Reviewed Literature
Findings indicated that employee motivation is significantly correlated with
growth opportunities, organizational culture and monetary compensation in the
Metropolitan Area Acute Trust Hospital and the Suburban University Area Acute Trust
Hospital. These findings have support from existing literature and are critical in
influencing intrinsic motivation of health care worker performance (Okello & Gilson,
2015). This study adds to the existing literature on employee motivation by providing
information on employee motivation after metamorphose conglomerate health care
systems. As was the case with this study, Okello and Gilson (2015) and Karlsberg et al.
(2015) found that good management practices, resources, professional development
activities, employee trainings and culture play critical roles in establishing trusting
relationships that promote intrinsic motivation. Das et al. (2015) found that employees
who are given opportunities for ownership value themselves more and are motivated to
indulge them in creative ideas. Das et al. (2015), Ray (2016), Hee and Kamaludin (2016)
and Yeboah and Abdulai (2016) concluded that rewards and recognition, monetary
compensation and career development opportunities, working conditions, and
promotional opportunities motivate employees when there is clear communication with
management. These findings align with the study’s results.
Studies examining growth opportunities on aspects of employee motivation are
scarce. Correspondent to the results of this study, Echoles (2016); Marete (2016); Gautam
(2016); Babic, Savovic and Domanovic (2014); Alhassan et al. and de Wit (2013);
Swarna and Nantha (2017); Lundin et al. (2015) and Rodriguez and Walters (2017) found
that employee advancement opportunities, better working conditions, a democratized
work environment, strong leadership, organizational citizenship, career management and
modification of job design, a competence management system to document employee
competence to improve quality of care, training and development opportunities, as well
as, effective employee performance assessments for improving employee engagement,
morale and overall competencies. In this current study, growth opportunities were
significantly correlated with employee motivation. This result was comparable to
expectations based on the findings of previous studies linking growth opportunities to
employee motivation. The expectation was that growth opportunities would differ in
public health care systems based on the differential influence of skilled health care
workers. In contrast, the result of this study indicated growth opportunity is significantly
correlated with employee motivation. The results align with the conclusion of Rodriguez
and Walters (2017); Coventry et al. (2015) and Cocuľová, (2017) that the importance for
organizations to provide employees with training and development opportunities, as well
as, effective employee performance assessments for improving employee engagement,
morale and overall competencies. The conclusion of Das et al. (2017) also align with the
results of the study that the employee’s perception about the time and effort their
employer is putting into their training will be perceived as an investment in them and they
are more likely to stay on the job. By 2030, the growth rate for health care workers
globally will rise to 80 million workers resulting in a worldwide shortage of 15 million
health care workers (Liu, Goryakin, Maeda, Bruckner, & Scheffler, 2017). The growth
rate is driven by economic and population growth and aging (Liu et al., 2017). This
shortage will fuel global competition for skilled health care workers (Liu et al., 2017).
Studies examining organizational culture on aspects of employee motivation are
plentiful. Resembling the results of this study, Belias and Koustelios (2014); Nica and
Potcovaru (2017); Jalal (2017) and Abbasi and Dastgeer (2017) found that hierarchy
organizational culture promotes knowledge governance in organizations to provide
opportunities for employees to share and enhance positive behavior at the workplace. In
this study, organizational culture significantly correlates with employee motivation. The
expectation was that organizational culture would differ in public health care systems
based on the differential influence of social identity and culture. In contrast, the result of
this study indicated organizational culture is significantly correlated with employee
motivation. The results align with the conclusion of Reis et al. (2018); Gabriel et al.
(2017) and Nica and Potcovaru (2017) that public hospital administrators must aim to
strengthen the group/human type of culture to produce positive overall quality
management, job satisfaction, profitability and commitment; employees must share the
values and beliefs of the company and that underdeveloped organizational culture
evaluations should be tied to strategies designed to develop the culture.
Studies examining monetary compensation on aspects of employee motivation are
limited. Similarly, the results of this study, Kuppuswamy et al. (2017); Hussain and Thau
(2017) and Beus and Whitman (2017) found that money is not adversely associated with
cooperation, although the salience of money is associated with increases in self-serving
behaviors and employee self-censorship on compensation matters may be an unintended
consequence of organizational emphasis on work meaning. In this study, monetary
compensation significantly correlates with employee motivation. The expectation was
that monetary compensation would differ in public health care systems based on the
differential influence of skilled health care workers. In contrast, the result of this study
indicated monetary compensation is significantly correlated with employee motivation.
The study’s results align with the conclusion of Kuppuswamy et al. (2017) that
organizations that make wages and salaries competitive within their industry will attract
and hold people.
Interpretation of the Findings in the Peer Reviewed Literature for the
Theoretical Framework
Herzberg’s Motivation-Hygiene Theory
The underlying argument of motivational-hygiene theory found that when
intrinsic and extrinsic rewards are present, employees may experience job satisfaction
(intrinsic) or job dissatisfaction (extrinsic). To address the research hypotheses, an
examination of growth opportunities, organizational culture and monetary compensation
on employee motivation responded to these rewards. Descriptive statistics results
indicated that the theoretical framework align with the findings.
The descriptive statistics results from the study are consistent with the
propositions of the theoretical framework. The hypothesized variables in the study were
significantly correlated. The findings align with conclusions by other researchers who
relied on the motivational-hygiene theory as a framework. Scholar’s Riggio (2016); Ray
(2016) and Shirol (2014) examined Herzberg’s motivation-hygiene theory on aspects of
employee motivation found that motivators such as the type of work, the level of
responsibility associated with the job, recognition opportunities, personal achievement
and advancement are inherent in the work itself and are related to job content. And
hygiene factors such as benefits, working conditions (both physical and social)
supervision, company policy and base salary are related to job performance. In this
study, Herzberg’s motivation-hygiene two-factor theory aligns with the conclusion of
Herzberg’s (1959, 1987) theory, that motivator and hygiene factors relate to the rewards
that flow from the nature of the work and the outcome performance of that work.
Conversely, Vijayakumar and Saxena (2015) found that Herzberg’s motivation-hygiene
theory is impractical in explaining how job satisfaction and motivation address
organizational culture in the workplace. Vijayakumar an Saxena (2015) suggest further
research on organizational culture when using Herzberg’s Motivation-hygiene theory on
culture.
Social Identity Theory
The social identity theory also aligns with the hypothesized variable. Ismail et al.
(2016); Joseph (2014); Elstak et al. (2015) and Cho et al. (2014) found that group
cultures, rational and development, contribute to organizational identification. In this
study, organizational culture significantly correlates with the social identity theory. The
results align with the conclusion of Cho et al. (2014) that employees who feel deprived of
an individual or a group level are less likely to identify with the organization.
Limitations and Delimitations of the Study
Cronbach's alpha was used to estimate the scale quality. Evidence from previous
studies was used to substantiate scale choices. The reliability was consistent of scale
scores when constructs were assesses. The broadness of the operational of items did not
affect scale quality estimates, meaning that very high estimates are indicative of low
validity. Assumption violations such as unidimensionality and uncorrelated errors of all
items were mitigated by identifying and excluding questions from the calculation of the
factor score for further analyses. The minimum reliability standards were .70 and .80.
These standards were used to determine whether the decision criterion was satisfied by
the observed reliability coefficient.
Validity was assessed by undertaking a scale reliability analysis in SPSS on the
survey data questions used in the study to compute Cronbach’s alpha. This approach
provided information about the structure and factors as designed. Therefore it was more
appropriate than using an exploratory analysis of the questions which investigates
alternative factor structures. Items that had a factor loading less than .04 were excluded
from the list of items.
Although the secondary researcher was not involved in the collection process, the
data were not affected by a problem such low response rate or respondent
misunderstanding of any survey questions. Information that was missing from the
dataset, such as demographics collected in the primary study, were not available to the
researcher due to confidentiality reasons.
Assumptions
This study examined theoretical assumptions. The motivation-hygiene and social
identity theories framed the study. The first the theoretical assumption for the two
theories indicated that specific natural groupings of phenomena existed. Meaning that
classification did occur and generalization within a category was meaningful. The
dependent and independent variables categorized each operational variable. For example,
the dependent variable, employee motivation was operational using the variable I look
forward to going to work.
The second theoretical assumption controlled scientific observation so that
association was attributed correctly. The specific research problem of interest was public
health care systems face internal structural issues and inefficiencies in organizational
practices and performance outcomes. The two theories permitted the researcher to
transition from describing the phenomenon observed to generalizing the various aspects
of that phenomenon. Science assumes some degree of constancy, or stability, or
permanence in the world objects and events and must retain some degree of similarity
from one time to another (Miner, 2015).
And finally, the theoretical and empirical literature supported the determination of
the research problem. Riggio (2016); Ray (2016) and Shirol (2014) found that motivators
in the Herzberg’s motivation-hygiene theory such as the type of work, the level of
responsibility associated with the job, recognition opportunities, personal achievement
and advancement are inherent in the work itself and are related to job content. And
hygiene factors such as benefits, working conditions (both physical and social)
supervision, company policy and base salary are related to job performance. Herzberg’s
motivation-hygiene theory aligned with the conclusion of Herzberg’s (1959, 1987)
theory, that motivator and hygiene factors relate to the rewards that flow from the nature
of the work and the outcome performance of that work. On the contrary, Vijayakumar
and Saxena (2015) found that Herzberg’s motivation-hygiene theory is impractical in
explaining how job satisfaction and motivation address organizational culture in the
workplace. Therefore, the social identity theory supported the study to align with the
hypothesized variable, organizational culture. Ismail et al. (2016); Joseph (2014); Elstak
et al. (2015) and Cho et al. (2014) found that group cultures, rational and development,
contribute to organizational identification. The results align with the conclusion of Cho
et al. (2014) that employees who feel deprived of an individual or a group level are less
likely to identify with the organization. The peer-reviewed research provided an
objective and rationale for the area of study. The results of the study will offer students
and scholars current knowledge in the research area for future studies. The relevance of
the theories was applied to the research problem to produce the appropriate conclusion.
Recommendations
The findings of this study indicated a significant correlation between employee
motivation, growth opportunities, organization and monetary compensation of public
health care workers. Using a sample of 3,033 public health care workers from a
Metropolitan Area Acute Trust Hospital and a Suburban Area Acute Trust University
Hospital in the United Kingdom, I examined the correlation between employee
motivation and growth opportunities, organizational culture and monetary compensation.
Recommendations for further study include using secondary data with demographics
rather than secondary data with no demographics as was the case for this study.
Subsequent studies using secondary data with demographic variables could allow a better
understanding of employee motivation in public health care organizations after they
become conglomerated health care systems. Another recommendation for future studies
is to determine whether a University Area Acute Trust Hospital offer more learning and
training opportunities to their employee than a General or Community Area Acute Trust
Hospital.
Implications for Social Change
The importance of the study will impact positive social change to individual,
families, organization and societal policy-making level. Brownson et al. (2017) and Cho
et al. (2014) noted the importance of informing and providing policymakers, hospital
administrators, researchers, human resource managers, and other stakeholders of various
approaches to improve health care services and practices such as the importance of
postmerger integration from an employee’s perception, adoption, implementation,
adaptation, and sustainability of evidence-based health interventions. Ghiasi et al. (2017)
asserted that research on organizational behavior in the context of consolidated health
care system practices and outcomes will provide a meaningful contribution to the
empirical literature in the area of public administration and will provide managers,
policymakers and researchers with current knowledge in the perspective of public health
services. Further amendments and implementation of laws can improve the performance
of health care systems by encouraging more affordable access and efficient organization
and delivery of health care (Davis et al., 2014). Health Information Technology can
inform stakeholders about experiences of other countries that may be relevant to their
state of affairs and report the comparative analysis of health care systems (Chevreul et al.,
2015). Models can be implemented and evaluated within academic centers to show that
the translation of science to practice is an academic discipline with methods and
outcomes that can be assessed like any other discipline (Brownson et al., 2017, p. 12). To
bridge the gap between an organization's current and desired state, organizational leaders
can commit to support the successful implementation of change and implement strategies
that will change employees' perception of their ability to carry out changes.
A theoretical social change from this study contributes to the motivationalhygiene
theory by explaining the phenomena of employee motivation in the context of practices
and outcomes in public health care systems. This study also contributes to the social
identity theory by explaining the phenomena of dynamics of language and speech
in the context of practices and outcomes in public health care systems.
Summary and Conclusion
Public administrators, health care workers and the Department of Health and
Human Services are affected when there are issues in health care behavioral practices and
performance outcomes. This correlational study examined the statistical relationship
between growth opportunities, organizational culture, monetary compensation and
employee motivation. The problem examined was public health care organizations
merged into new systems, but the culture for each merged organization has not been
formed under the new system creating internal practice and performance outcome issues.
Health care workers must adapt to system changes. In a study conducted by Platis
et al. (2015), they found that in a health care service environment of tension and division
of labor, the most basic challenge is the performance of employees. Other scholar’s such
Okello and Gilson (2015); Knies et al. (2017) and Carayon et al. (2014) contended that
health care workers form the backbone of any health system and the key principle for
improving health care quality are balancing the work system and encouraging the active
and adaptive role of workers which is critical to the delivery of services.
The results of this study found that there is a correlation between employee
motivation and growth opportunities, organizational culture and monetary compensation.
These results support Ghiasi et al.’s (2017) research that there is limited to non-existence
of prominent organizational behaviors in health care systems. Researchers, the
Department of Health and Human Services, health care workers, community members,
patients and funders will benefit from the study’s recommendations.
