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How to improve motivation

Dr Raj Persaud
Consultant Psychiatrist
The Maudsley Hospital,
London

Curiously and sadly, the theories of motivation still widely employed on nurses by those who plan the health service are precisely the ones psychologists demonstrated long ago just don't work.
A key theory is known technically as the "kick in the ass" method (KITA), which basically means that you get punished, humiliated, sacked, docked wages, and so on, if you are not cooperating with your clinic. This approach merely leads to most chronically demotivated employees investing huge effort in avoiding being caught not producing the goods, and so dreaming up complex schemes whereby the pretence of hard work is maintained, usually at just the level required to avoid a KITA.
The key to motivating nurses comes from research that asked a very basic question, but one which goes to the heart of psychology of work: "What do you find most rewarding about work?" Few of those who plan our health service ever pose this question themselves. The answers are all psychological and often have little to do with money (beyond a sense of being fairly paid), and certainly have nothing at all to do with avoiding a KITA.
In order, the most frequently cited and strongest rewards that people find most motivating in the workplace are: a sense of achievement, recognition from colleagues of your good work, enjoying aspects of the job in itself, a sense of responsibility (ie, it matters if you don't do a good job), a sense of career advancement and, finally, a feeling of personal growth.
What is fascinating about this is how little work environments are designed to produce any of the rewards on the list. Meetings convened by seniors, for example, which could be used to acknowledge good work from individuals, often turn into a chance for a KITA instead!
So, what the latest thinking in the psychology of motivation finds is that the very opposite of what is usually being done at work needs to be implemented in order to improve drive. For example, instead of carrots and sticks, people actually need to be given more freedom to do the job the way they want to do it, rather than as dictated by policy, guidelines or managers. This gives them a sense of personal responsibility and ownership of their work. Nurses also need some shared sense of what counts as doing a good job, which can be fed back to them so they can feel personal pride in better performance. Managers and nurses often don't agree on the key goals of the organisation, and as a result what an employee thinks is  the aim of their work is not what the management thinks.
Nurses also need to be given "natural" units of work that are more likely to be found personally rewarding, as achievement is then more obviously discernible. To take an example from my own experience, the way the NHS is increasingly managed means patients are always further divided between teams who superspecialise in different aspects of care, so now no one doctor or nurse takes overall responsibility for the individual patient. But then no one doctor or nurse feels the benefit as the patient recovers or obtains a sense of responsibility for that patient.
Managers and workers need to sit down together and think about how the work fits in with the longer-term personal and career goals of the workers - this is the best way of retaining employee loyalty and stops them jumping ship as soon a better job offer comes along. How the work helps you develop, in terms of the skills it assists you in growing, is vital in helping build a sense of improving capacity to deal with more difficult challenges.
This motivational strategy, with its multiple approaches of focusing on improving the psychological reward of going to work, is globally termed "job enrichment". At its heart is the understanding that the most motivated people in the world tend to work extremely hard without much direct financial reward being the core reason for their motivation (they often are relentless even in the face of poor rewards - that's how we recognise them as being motivated). The deeply motivated are also those who work hard even if no one is checking up on them - again, another sign of how we know they are motivated.