Catherine Adams

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Adams's equity theory has its basis

in organizational justice concepts.

12.4 Cognitive Process Motivation Models

One of the primary criticisms of the reinforcement­based approaches to motivation and learning has been

that the theories do not explain complex reasoning processes. Such thought processes deserve attention,

especially in complex environments such as healthcare organizations. In essence, employees are likely to

consider their circumstances and then respond in some way. Two cognitive process models of motivation

include Adams's equity theory and Vroom's expectancy theory.

Adams's Equity Theory and Organizational Justice

Among the more common factors that might influence a person's behavior on the job is the perception

that a given process is fair. Equity theory, as developed by J. Stacy Adams (1963, 1965), explains how

employees might react to perceptions of both fairness and inequity. The theory explains various responses

in healthcare organizations as well as other settings.

Inputs and Outcomes

At work, people exchange inputs for outcomes. Inputs include

everything an employee trades to an organization, expecting

something in return. Examples of inputs include education,

experience, special skills, levels of effort and productivity,

helpfulness to others, creativity or suggestions, grooming and

cleanliness, attention to patient needs, maintaining confidentiality,

and other duties. Outcomes are the items the organization

exchanges for inputs. Outcomes include pay, praise, chances to be

promoted, status symbols (corner office; reserved parking space),

company benefits, job assignments, recognition, job security, and

being included in organization plans and decisions.

Presence of a Referent Other

A referent other is a person (or possibly a group) chosen by an

employee for purposes of making social comparisons. In other words, most employees tend to single out

someone at work or in some other organization for the purpose of examining relative levels of inputs and

outcomes. Most of the time, a referent other will be someone who was hired at about the same time and

performs the same or a comparable job. In other circumstances, different forms of referents are selected,

as displayed in Table 12.7.

Table 12.7 Potential referent other comparisons

Comparison type Description

Self inside the organization The employee compares a new position or job

to a previous position or job in the same

organization.

Self outside the organization The employee compares a current position or

job to a previous position in a different

organization.

Other inside the organization The employee compares a current job or

position with another person or group within

the same organization.

Other outside the organization The employee compares a current job or

position with another person or group in a

different organization.

The Comparison

No matter which type of referent other emerges, the employee compares input–outcome ratios—that is,

give–get relationships, or "what I give and get versus what my referent other gives and gets."

  Personal outcomes

versus

 Referent other outcomes

    Personal inputs     Referent other inputs

Equity Perceptions

Equity occurs when the ratio comparison is perceived as being equitable, in balance, or fair. For instance,

Joe serves as a nurse in a mental health facility. His inputs include distributing medicines on a nightly

basis, assisting a patient during exams under the supervision of a physician, tending to a patient's needs

when an individual is moved to the infirmary, and providing help in emergency situations. Joe's outcomes

include pay of $22 per hour and flexible scheduling in which he can switch shifts with other employees if

he desires a particular night free.

Susan is the nursing supervisor. Her inputs include hiring, training, and firing employees; completing daily

report sheets; working on a fixed schedule with no shift switching; and assisting with nursing duties when

required. Her outcomes include pay of $27 per hour and an extra week of paid vacation (four instead of

the three that all other nurses get) each year.

Even though Susan earns $5 per hour more and has more vacation time, Joe believes the differential is

equitable. Susan gives more to get more; Joe gives less and receives less. When such a sense of equity or

equilibrium exists, behavior is maintained. The definition of motivation as noted at the start of this

chapter includes "what maintains behavior." In this instance, a sense that things are equitable or fair

means Joe will keep working at the same pace and with the same level of intensity.

Perceptions of Inequity

Many times, a review of personal and referent other inputs and outcomes leads to the perception that

the formula is not in balance. This circumstance—inequity or disequilibrium—results in a strong

motivational force (a cognitive process) to restore equilibrium. In other words, the individual feels

compelled to somehow adjust the components in the input–outcome ratio. Table 12.8 represents the

types of reactions that are possible.

Table 12.8 Reactions to perceptions of inequity

Activity Example

Change personal outcomes Ask for a pay raise

Change personal inputs Try harder or reduce effort

Influence referent other

outcome

Encourage referent other to ask for a raise

Influence referent other

inputs

Encourage referent other to try harder or reduce

effort

Change referent other Look at outcomes and inputs of someone

different

Rationalize Add elements to the formula, such as a time

horizon

Leave the field Quit the job

One set of reactions to inequity involves a perception described as positive inequity, as reflected in this

formula:

 Personal

outcomes

>

 Referent other outcomes

   Personal inputs    Referent other inputs

This formula suggests that the person involved has determined that he or she is overpaid, because the

person's outcome–input ratio is more generous or valuable than the ratio the referent other experiences.

Using the potential responses noted in Table 12.8, a person who felt overpaid could try harder and

produce more inputs to justify the difference, change comparisons to a referent other who earns more, or

rationalize that the pay difference was based on seniority or some other factor not previously considered.

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

 Personal outcomes

<

  Referent other outcomes

   Personal inputs    Referent other inputs

This situation reflects feeling underpaid. A person who believes he or she is underpaid could ask for a pay

raise; reduce outputs (don't try as hard); conclude that although the employee currently experiences

inequitable treatment, management will eventually make things right through a promotion or some other

future adjustment to outcomes; or make plans to leave and quit.

Support for Equity Theory and Organizational Justice

There is significant theoretical support to validate equity theory. The idea that people exchange inputs for

outcomes in all types of social interactions with others has its basis in psychological contracts (Schein,

1982). The idea that people compare themselves to one another is based on social comparison theory

(Festinger, 1954, 1957).

Furthermore, the premise that inequity exists when input–outcome ratios differ is founded in the

principles established by the theory of distributive justice—people should receive in proportion to what

they give in society, which also applies to the allocation and amount of outcomes. Awareness of equity

and inequity are influenced by perceptions of procedural justice, or evaluations of the fairness of a

process, such as a performance appraisal or pay raise system. Distributive justice and procedural justice

combine to create perceptions of overall organizational justice (Dailey & Kirk, 1992).

Finally, the tendency to act on disequilibrium derives from conceptualizations of cognitive dissonance

(Festinger, 1957). Cognitive dissonance, or mental disharmony, creates a mental force seeking to resolve

the discord or dissonance.

Complications

Although organizational research supports the predictions of reactions by individuals to perceptions of

inequity (Scheer, Kumar, & Steenkamp, 2003), a series of complications have been associated with the

work. One of those complications involves equity sensitivity, or the range of reactions to perceptions of

inequity. Equity "sensitives" believe firmly in reciprocity and become quickly motivated to resolve feelings

of being over­ or underpaid. Equity "benevolents" are more altruistic and less bothered by underpaid or

negative equity relationships. Equity "entitleds" respond most vigorously to negative equity or underpaid

circumstances and may remain frustrated until positive equity or an overpaid comparison appears (Sauley

& Bedeian, 2000).

In addition, feeling overpaid does not seem to change a person's behaviors at work, possibly because the

individual quickly rationalizes differences in outcomes (Steers, 1996). The theory does not account for the

power of the rationalization process in overpaid, as opposed to underpaid, situations.

On a more practical level, the social comparisons that could be made within an organization are both

countless and unpredictable. Managers do not choose who someone singles out for a social comparison,

and the choice could be completely inappropriate. For instance, a new, fresh­out­of­dental­school

hygienist who compares herself to someone with eight years of experience might result in inaccurate

perceptions of deserved outputs and inputs.

Finally, equity theory may not represent thought processes in other cultures. Many national cultures do

not contain strong feelings regarding distributive justice. Also, in former communist countries, feelings of

entitlement can supersede perceptions of equity and distributive justice. Thus, many organizational

behavior experts view the theory as culture bound (Giacobbe­Miller, Miller, & Victorov, 1998). Given the

number of foreign­born physicians and medical professionals working in the United States today,

healthcare managers should consider this issue in implementing the basic concepts.

Managerial Implications

Despite the concerns with equity theory, however, many healthcare managers may find that its principles

offer value. To begin, a supervisor can make certain that the equity comparisons made by top performers

receive the most attention. Doing so can go beyond pay and benefits. For example, top performers may

receive preferential treatment in terms of scheduling breaks during the work day, vacations, and other

nonfinancial signals related to their worth. At the same time, each employee should believe that the

reward system is fair and is not simply based on the manager's personal preferences.

Managers can also employ equity theory to understand why workers become dissatisfied and seek to

leave a company. In essence, it provides a framework for understanding how employees react to how

they are treated by the organization and specific managers.

Vroom's Expectancy Theory

Vroom (1964) provided a second cognitive process theory to explain the relationships between

organizational circumstances and employee motivation. Several variations of the theory's concepts may be

found in the literature. Each version contains three primary elements: expectancy, instrumentality, and

valence.

Expectancy summarizes an individual's belief that a given level of effort will result in successful

performance of a task. A medical student who expresses complete confidence that she will pass her

licensure exams expresses a high expectancy. Another student who believes passing the exam on the first

try will not be possible has an extremely low expectancy value. Any provider who does not believe he can

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cure a patient experiences a lower level of expectancy; when the same provider has great confidence the

patient can be cured, expectancy takes on a high value. Expectancy can be depicted as follows:

Effort → Performance

Instrumentality reflects an individual's belief that successful performance of a task will result in a specific

outcome or reward. A physical therapist who believes he can treat an injury and will be fully financially

compensated by the patient and his insurance company expresses a high instrumentality score. An intern

who believes her supervising physician holds a grudge and will not write a positive endorsement of her

work, no matter the quality of that work, has an instrumentality score that is low or even zero.

Instrumentality may be expressed as this linkage:

Performance → Reward

Valence consists of two components. The value of the reward to the person constitutes the first. If a

pharmaceutical company holds a sales contest in which the reward for winning is an all­expenses­paid

vacation to Hawaii, the majority of salespeople will highly value the prize. Thus, the valence of the

outcome will be high. If the same contest yields a prize of a free dinner at a local restaurant, and most of

the salespeople dine out all the time as part of their travels (which means they are not excited at all

about the reward), then the valence of the outcome will be low or zero. The second component of

valence is the value associated with achieving a goal or successfully completing a task. Winning the

contest provides a valence associated with doing the best job during a specific time period on a given

task.

Calculating a Motivational Force

Individual authors have presented several versions of the combinations of these variables. A common

method uses a multiplicative model, as follows:

Motivational force (effort) = Expectancy × Instrumentality × Valence

Values can then be assigned to each variable. Expectancy may

be rated from 0 to 1 or 0 to 100%. A score of 0 means the

individual believes no linkage between effort and

performance exists, or "No matter how hard I try, I can't do

it." A score of 0.5 or 50% indicates the person believes he or

she has a 50–50 chance of success, given a specific level of

effort. A rating of 1 or 100% indicates the person has

complete confidence that given a certain level of personal

effort, the individual can complete the task or achieve the

goal.

Motivation only occurs when valences,

expectancies, and instrumentalities all

reach high levels.

The same formulation applies to instrumentality. A score of 0

means the person does not believe a reward will be delivered

for successful performance. A score of 50% suggests the

individual is uncertain about whether the reward would be

delivered. A value of 100% means the person expresses complete confidence that achieving a goal or

successful performance will be rewarded.

Assigning values to valence is more problematic. Scales can be used to indicate the value of a reward from

1 (no value) to 7 (great value), or sets can be used to indicate low, medium, and high degrees of valence.

The concept behind these ranges is to note that some valences are more powerful than others.

Using this approach makes it possible to see differences in the degree of motivational force and to make

predictions about the level of effort that will be given (see Table 12.9).

Table 12.9 Degrees of motivational force

Motivational

Force

= Expectancy × Instrumentality × Valence

High = High × High × High

Moderate = High or

Moderate

× Moderate × High

Low = Low or

Moderate

× Low or

Moderate

× Low or

Moderate

The highest level of effort would be expected when the individual believes he or she can successfully

complete a task (high expectancy), that successful completion of the task will result in a reward (high

instrumentality), and that the reward itself has value (high valence). Under any other circumstance, the

degree of motivation diminishes. Notice also that if a score of 0 is assigned to any of the three variables,

the resulting level of motivation will also be 0.

Advantages of Expectancy Theory

Expectancy theory has been a well­respected approach to understanding motivation in the workplace for

several decades and for several reasons. First, the theory concentrates on workplace motivation rather

than motives in other circumstances. It applies to specific employment activities, goals, and rewards.

Second, using the formulation shown in the previous section, expectancy theory explains not only

circumstances in which employees will be motivated but also situations in which they will not be

motivated. An organization that has not given pay raises or any other incentives for performance over the

past three years should not be surprised by the levels of effort exhibited by its employees. When a linkage

Motivational Strategies

between effort and performance cannot be identified, motivational levels decline. Furthermore, managers

who fail to recognize the things that employees value may offer rewards with little or no meaning to

those employees.

Third, the theory incorporates both intrinsic and extrinsic motives. An intrinsic valence is the reward a

person experiences after achieving a goal, such as a feeling of pride, accomplishment, or self­efficacy.

Intrinsic valences accompany the extrinsic valences, or the strength of the rewards given by others (Porter

& Lawler, 1968). In medical circumstances, helping others, relieving suffering, healing patients, and

providing quality care to patients and their loved ones all constitute a powerful set of intrinsic motives for

many healthcare employees in a variety of jobs. Managers should never underestimate the importance of

these intrinsic valences.

Fourth, there is consistent research to support expectancy theory (Donovan, 2001; van Eerde & Thierry,

1996). Many managers believe that the theory offers down­to­earth, concrete methods for seeking to

improve employee effort and levels of motivation. In essence, applying expectancy theory involves three

things: working to make sure employees can complete assigned tasks, linking performance to the reward

system, and making sure employees are rewarded with the things they value.

Does Money Motivate Healthcare Workers?

One continuing debate in organizational

behavior focuses on the role of money as a

motive. In some of the theories presented in this

chapter, pay only manages to dissatisfy

employees. In others, money includes the

concept of valence, or something that holds

value and thus serves to motivate individuals.

Money in healthcare holds an even more unique

role. People working in the industry clearly do so

to support themselves and their families. And

yet much of their work concentrates on the

helping aspects of serving patients. Employees

balance considerations, such as the desire for a

quality standard of living, with other factors.

Recently, many private practice physicians have

encountered circumstances in which some

patients have made fewer trips to the doctor's

office, and others have decided to forgo more

expensive (and lucrative to physicians) elective procedures. The result has been an increase in doctors

filing for bankruptcy (Kavilanz, 2013) and, as a result, some regions are losing access to certain forms of

healthcare. In several instances, the physicians had not lost any major medical malpractice lawsuits and

were considered to be highly respected doctors. Instead, economic downturns had shaped patient

decisions regarding healthcare. In addition, declining insurance reimbursements, changing regulations, the

rising costs of malpractice insurance, drug costs, and other business necessities were deemed as culprits.

In the coming years, the role of money as a motivator for individuals in the healthcare system will

continue to receive scrutiny. Doctors, nurses, and others employed in the system battle expensive training

programs, long hours on the job, work­related stress, and other factors, all while seeking to serve others.

Those involved in managing the system will need to discover ways to make sure the industry attracts and

retains quality employees. The role money plays in that system remains to be seen.

CASE

Debbie's Dilemma

Debbie Vestica decided to look for a new job on a day that should have been filled with joy. She had

just completed a master's degree in nursing and had been given a substantial increase in pay, along

with new benefits. Other factors, however, greatly diminished the reward she had just received.

Debbie began working as a nurse in a local pediatric physician's medical group. Three doctors and

three nurses made up the medical staff. Two of the nurses completed training at the licensed

practical nurse (LPN) level, while Debbie held the rank of registered nurse (RN). Due to this

difference in educational attainment, Debbie was expected to supervise the other two nurses. The

problem she faced was that the two nurses often treated her more as a peer, or even as a

subordinate, rather than as a supervisor.

To complicate matters, the two LPNs had been on staff for four and five years, respectively, while

Debbie had only been employed by the organization for two years. Still, when hired, she was told to

assume a supervisory role. At first, Debbie chose not to confront the two more experienced nurses,

hoping that over time she would be able to manage them more effectively by not trying to use

forceful or directive tactics.

One year later, Debbie discovered that although her pay was slightly above average for RNs in the

area, her pay differential with the LPNs was only $3 per hour. She earned $30 per hour ($60,000 per

year), whereas the LPNs earned $27 per hour ($54,000 per year). Their pay ranked them above

nearly all LPNs in the state. Given the additional duties she was expected to complete, Debbie found

the pay differential to be unsatisfactory.

After two years on the job, Debbie began a master's program designed to achieve the designation of

clinical nurse specialist with an emphasis in children's health. She devoted considerable time and

money to obtaining the degree, although the physician's group did contribute 50% of her tuition and

book costs.

On graduation day, Debbie met with the three physicians. They all generously praised her efforts and

promised her a new status level that included having her own office in the complex. They also

granted her a raise of $7 per hour, raising her annual salary to $74,000, in return for additional

duties and responsibilities.

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

Upon finding out about Debbie's new pay raise and status, the LPNs confronted the three physicians,

demanding an additional increase in pay as well. Sensing a major confrontation, the physicians had

decided to raise the pay of the two by $5 per hour, to $32 per hour or $64,000 per year. That

amount was higher than what Debbie had earned as an RN and as an RN attending graduate school.

Believing that she would never receive the proper pay differential that she deserved in this practice,

Debbie decided it was time to seek employment elsewhere.

1. Use Herzberg's two­factor theory to explain Debbie's level of motivation.

2. Use Adams's equity theory to explain Debbie's decision to look for work elsewhere.

3. Use Vroom's expectancy theory to explain this situation.

4. If you were advising the three physicians in the organization, what would you tell them they

should have done when confronted by the two LPNs? Defend your advice.