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The motivation
The motivation to care to care
Application and extension of motivation theory
to professional nursing work
Roseanne C. Moody and Daniel J. Pesut 15
Indiana University School of Nursing, Indianapolis, Indiana, USA

Abstract
Purpose – The purpose of this research is to describe a model of nurses’ work motivation relevant to
the human caring stance of professional nursing work.
Design/methodology/approach – The model was derived from selected theories of behavioral
motivation and work motivation. Evidence-based theory addressing nurses’ work motivation and
nurses’ motivational states and traits in relation to characteristics of organizational culture and patient
health outcomes is suggested in an effort to make a distinct contribution to health services research.
An integrated review of selected theories of motivation is presented, including conceptual analyses,
theory-building techniques, and the evidence supporting the theoretical propositions and linkages
among variables intrinsic to nurses’ work motivation.
Findings – The model of the Motivation to Care for Professional Nursing Work is a framework
intended for empirical testing and theory building. The model proposes specific leadership and
management strategies to support a culture of motivational caring and competence in health care
organizations.
Originality/value – Attention to motivation theory and research provides insights and suggests
relationships among nurses’ motivation to care, motivational states and traits, individual differences
that influence nurses’ work motivation, and the special effects of nurses’ work motivation on patient
care outcomes. Suggestions for nursing administrative direction and research are proposed.
Keywords Nursing, Motivation (psychology), Leadership, Health services
Paper type Research paper

Competence and caring among nurses are professional expectations. Nurses have both
a moral and ethical duty to treat patients competently in a caring and professional way.
Yet the nursing profession continues to struggle with multiple complex issues that
affect nurses’ efforts to be competent, caring healthcare professionals. Current nursing
workforce shortages have had a negative impact on nurse morale and staffing; and
such shortages challenge recruitment and retention efforts worldwide (Aiken et al.,
2001). High nursing turnover and lack of adequate nurse staffing is linked to decreased
nurses’ work satisfaction, decreased patient satisfaction with the quality of nursing
care, and poorer health outcomes for patients (Aiken et al., 2001; Leiter et al., 1998;
Needlemen et al., 2002; Strachota et al., 2003). Overall, the quality of health care is
affected by interactions among these complex variables, and therefore it is necessary to
begin to discover the connections between motivational issues in professional nursing Journal of Health Organization and
work and patient care outcomes. Management
Vol. 20 No. 1, 2006
pp. 15-48
q Emerald Group Publishing Limited
The authors express gratitude for editorial assistance to Dr. Phyllis Dexter, Associate Professor, 1477-7266
Indiana University School of Nursing, Indianapolis, Indiana. DOI 10.1108/14777260610656543
JHOM Nursing care is influenced by context, culture, and individual differences among
20,1 nursing health care providers. In spite of the current challenges in the nursing
profession, most nurses transcend organizational problems and are motivated to serve
and care for patients in spite of difficult circumstances. However, there is little
understanding of the specific factors influencing nurses’ motivation to care, given the
need to establish meaningful and caring nurse-patient relationships in increasingly
16 complex healthcare organizational contexts.
To date there has been little investigation or theory development that specifically
addresses the motivation to care. Caring is an essential characteristic of professional
nursing practice, and is defined as attending to the special needs of human beings in
vulnerable contexts (Glen, 1998). How is that we might come to understand
relationships between an individual’s motivation and the nature of nurses’ human
caring work? What factors influence the nurses’ intention to care and how do such
intentions become actualized or limited in health care institutions? What effect, if any,
does enhancing nurses’ motivation to care have on patient care outcomes? How can
nurse leaders and managers influence and create cultures of caring that tap nurses’
motivation to engage in professional nursing work?

Purpose
Using applications and extensions of classic and contemporary motivation theory,
this paper puts forth a model of the motivation to care for professional nursing work.
In this paper classic and contemporary work motivation theories and the empirical
and theoretical treatments of these theories in the nursing literature are described and
analyzed. From the social psychological, social cognitive, organizational behavior,
and nursing literatures, a meta-theoretical model of nurses’ work motivation was
developed. Theoretical propositions to support relationships among concepts and
variables in the model are articulated. Evidence supporting the effect of individual
motivational states and traits on work motivation in the context of professional
nursing is presented. Finally, evidence-based leadership and management principles
to support nurses’ work motivation in the professional work that they do are
proposed.
This article is in part a response to Locke and Latham (2004), who call for theory
building that integrates general (trait) and situationally specific (state) motivation
issues at work. Human needs and values become operative in contexts of
complexity and culture (Locke and Latham, 2004). As Locke (1997, p. 392) reminds
us, “Goals are the specific form of values”. In other words, goals emerge from
values in the context of an individual’s personal and professional life. We agree that
a person’s values and needs are theoretically and practically linked in the context of
work. Such linkages provide clues to the motivation to care in the context of
professional nursing work.

Clarification of the definition of motivation

According to Locke (1997), motivation is determined by goal directedness, human
volition or free will, and perceived needs and desires, sustaining the actions of
individuals in relation to themselves and to their environment. Although this definition
appears to be comprehensive, it is put forward here for critique amid other competing
definitions found in the literature.
 There are many definitions of motivation in the literature, yet none that is The motivation
universally accepted and applied. In order to examine those multiple definitions, to care
concept analysis was undertaken with a distinct focus upon the nursing literature.
Hinds’ (1984) concept clarification criteria were applied to all of the definitions found in
the literature. Hinds (1984) argued that concept clarity is essential for theory-building
purposes. She asserted that clarity is evident when concepts have the following
characteristics: Context, continuum, conciseness, positive terms, absence of circularity, 17
and definitive essence related to the phenomenon being described. Table I summarizes
the analyses of selected definitions of motivation as a concept, using Hinds’ (1984)
criteria for evaluation.
As noted in Table I, no single extant definition of the concept of motivation
completely satisfies Hinds’ (1984) criteria for conceptual clarity. The definition
proposed by Janssen et al. (1999) meets five of six criteria. Work motivation is defined
as “. . .the degree to which a person wants to work well in his or her job, in order to
achieve intrinsic satisfaction” (Janssen et al., 1999, p. 4). Using Hind’s criteria for
concept clarity, the authors propose the following definition for motivation:
“Motivation is a values-based, psycho-biologically stimulus-driven inner urge that
activates and guides human behavior in response to self, other, and environment,
supporting intrinsic satisfaction and leading to the intentional fulfillment of basic
human drives, perceived needs, and desired goals”. We believe this definition meets
Hinds’ criteria for conceptual clarity in that it uses clear, concise, positive, noncircular
terms and language; it is in the natural context of self, other and environment; and it is
on an expressive continuum from internal values to external behavior.
Across studies and disciplines, the concept of motivation is at the heart of individual
and group incentives to act or not to act (Depue and Collins, 1999; Locke and Latham,
2004) The incentive to act implies self-determinative choice and is related to
expressions of one’s sense of personal power and autonomy (Deci and Ryan, 1985).
Environmental conditions that support individual self-determination foster a positive
sense of self-esteem, health, and personal and professional well-being (Ryan and Deci,
2000). Linking motivation to self-determination and self-esteem is an essential feature
of the motivation to care and professional nursing work. These relationships are
explored in depth in this paper. To support our synthesis we summarize selected
classic theories of motivation and work motivation. These theories provide the
background, supporting logic, and rationale for a meta-theoretical model of the
motivation to care for professional nursing work.

Classic theories of motivation

Empirically based understandings of human behavioral motivation are found in the
biological and affective neuroscience literature. Biologically based theories of
motivation provide a physiologic explanation for several theories of work
motivation based on perceived rewards and punishments for motivated and
non-motivated behavior. From a psychobiological perspective, perceptions of
positive or negative phenomena stimulate an individual’s motivated behavior
(Carver and White, 1994; Depue and Collins, 1999; Lehner, 1979). The behavioral
process itself is derived from biological models of animal and human behavior (Gray,
1990; Depue and Collins, 1999) that explain motivation as stimulus – response –
feedback in a continual loop cycle (Depue and Collins, 1999; Lehner, 1979). A stimulus
JHOM
Essence of Not Positive Clear,
20,1 Definition phenomenon circular terms concise Continuum Context

Rousseau and Tijorwala (1999), “Motivated

reasoning and social accounts in promoting
organizational change [motivated reasoning]”
“People seek causal explanations for unusual
18 or unexpected events. Motivated reasoning
addresses how a particular reason is adopted
to explain such an event” (p. 516). – þ þ – – –
Depue and Collins (1999), “Neurobiology of
the structure of personality: dopamine,
facilitation of incentive motivation, and
extraversion” “. . . incentive motivational
theory is meant to explain how goal-directed
behavior is elicited and guided by incentive
stimuli (or their central representations) in
interaction with central drive states . . . and
may be either positive or aversive . . . ” (p. 494). þ – þ – þ –
Fletcher (1999), “A concept analysis of
motivation” “Motivation is the inner urge that
moves or prompts a person to action” (p. 41). þ þ þ – – –
Cubbon (2000), “Motivational theories for
clinical managers” “Motivation is the term
used to describe those processes, both
instinctive and rational, by which people seek
to satisfy the basic drives, perceived needs
and personal goals, which trigger human
behavior” (p. 30). þ þ þ þ – –
Edgar (1999), “Nurses’ motivation and its
relationship to the characteristics of nursing
care delivery systems” “Motivation, the
central concept guiding human behavior, is
defined as that which activates, directs, and
sustains human behavior” (p. 14). þ þ þ þ – –
Joshua-Amadi (2002), “Recruitment and
retention: a study in motivation” “Motivation
is here defined as the driving force within
individuals that influences their choices of
behavior in performing tasks to achieve
desired goals or expectations” (p. 17). þ þ þ þ – –
Table I. Janssen, de Jonge, and Bakker (1999),
Clarification of selected “Specific determinants of intrinsic work
definitions of motivation motivation, burnout and turnover” “Work
(ascending order of motivation is defined as ‘the degree to which a
clarity based on Hinds’ person wants to work well in his or her job, in
(1984) method of order to achieve intrinsic satisfaction’ ”
evaluation) (p. 4). þ þ þ – þ þ

that “incents” or motivates an individual to act initiates a behavioral response to the

degree that the stimulus is perceived as rewarding (positive-approach) or punishing
(negative-withdrawal) (Carver and White, 1994; Depue and Collins, 1999; Gray, 1990;
Lehner, 1979).
 Thus, behavioral motivation has a moderating influence on individual behavioral The motivation
action (or inaction), within a particular context. Motivation that drives behavioral to care
action decisions influences an individual’s cognition, learning, and productivity in his
or her personal and professional lives (Depue and Collins, 1999; Fiedler, 2001; Gray,
1990). These theories provide useful insights that help explain motivation in work
contexts.
For example, in the classic work motivation theory of Herzberg (1968) and Hackman 19
and Oldham (1980), human volition or free will and a multitude of internal (self) and
external (environmental) factors influence a person’s intrinsic motivation. Classic
theories focus on the presence of intrinsic and extrinsic rewards as incentives to work.
These theories assume that a person’s motivation to work arises from the
characteristics of the jobs her or she performs. Thus job characteristics are linked
with work motivation and job satisfaction. Job characteristics assumed a prominent or
foreground role in these studies and human factors assumed more of a background
role.
Herzberg’s (1968) theory posited a two factor model of work motivation, namely
“job satisfiers” and “job dissatisfiers”. Job dissatisfiers defined extrinsic work
motivational factors. The absence of these conditions at optimal levels caused job
dissatisfaction. Examples of these factors included acceptable salary, job security,
work conditions, level and quality of supervision, quality of administration, and
interpersonal relations. These external conditions were viewed as pre-requisite to
meeting workers’ extrinsic motivational needs (Herzberg, 1968).
Classic theories also acknowledge that individual personal characteristics need
consideration as work is designed (Hackman and Oldham, 1980; Herzberg, 1968).
Characteristics reported to influence job satisfaction comprise the second factor of
Herzberg’s (1968) theory. Examples of intrinsic “job satisfiers” include achievement,
recognition, responsibility, and advancement. Specific job characteristics reported to
influence satisfaction derives from an individual’s intrinsic motivation to work and
include: Autonomy, job feedback, task identity, skill variety, and task significance
(Hackman and Oldham, 1980). The theory proposes that the more a job provides
certain extrinsic factors, including substantial freedom to act, effective feedback,
identifiable work, a variety of activity, and a perceived impact upon the lives of
others, the greater an individual’s intrinsic motivation at work (Hackman and
Oldham, 1980).
Hackman and Oldham (1980) argued that a triad of critical internal psychological
states is a necessary condition for high levels of employee motivation. These
psychological states include the meaningfulness of the work, knowledge of
responsibility for results of the work, and knowledge of the outcomes of the work.
These psychological states are mediating variables that influence employee
motivation, performance, and work satisfaction. The investigation of psychological
states is important work for motivational theorists. There is a need for theory synthesis
across disciplines to explain the influence of psychological states and traits on
motivation. Explanation of psychological states must consider issues of affect,
personality, cognition, and cognitive problem-solving. Research on individual
differences in relation to motivation and human performance at work is needed to
explain variables linked with individual differences, theories of motivation, and
relationships among personality and other psycho-social variables. Organizing and
JHOM linking research and theory in these areas provides more insights into the complexity
20,1 of work motivation.

Individual differences: associations among cognition, affect, personality

and behavioral motivation
Cognition
20 In fields such as health care in which human health and safety are a top priority, it is
important to be aware of research across the disciplines in order to understand the
biological, emotional, and motivational processes that influence an individual’s skill
and behavioral capacity to engage in astute cognitive decision-making at any given
point in time. Recent works in affective neuroscience, social cognitive, social
psychological, and organizational behavioral literature suggest that affect and
personality are important mediating factors in the study of human motivation,
cognition, and human performance (Ashby et al., 1999; Barrick and Ryan, 2003; Fiedler,
2001; Forgas, 2001; Moody, 2003).
Improved understanding of the cognitive-emotive interface in the thinking and
emotion systems of the human brain has led to explanatory models of human
motivation and performance. A certain part of the brain, the prefrontal cortex (PFC),
has been found to be involved in the integration of behavior, thinking, and emotions
(Goldberg, 2001; Lezak, 1995; Panksepp, 1998). As the richest network of neural
pathways of any brain structure, the PFC serves as the point of contact for both
external environmental stimuli and internal state information from the limbic
(emotion) system of the human brain (Goldberg, 2001; Lezak, 1995; Panksepp, 1998).
This area of the cortex has an impact on different types of memory and attention levels,
toward initiating appropriate behavior and cognitive decision-making processes
(Panksepp, 1998; Lezak, 1995). A related area of the brain, the anterior cingulate cortex
(ACC), communicates with the PFC. The ACC facilitates executive attention and
cognitive flexibility, stimulating higher level thinking associated with creativity, more
complex problem-solving, and improved emotional self-control (Allman et al., 2001;
Ashby et al., 1999; Goldberg, 2001).
It is important to note the evidence supporting an intimate connection between
human thinking and emotions. Research is beginning to show that the relationship
between the cognitive and emotive areas of the ACC may be inhibitory in nature, such
that stimuli that increase demands for emotional control may in turn reduce the
capacity for control of one’s thinking and decision-making processes (Allman, et al.,
2001; Bush et al., 2000). Since the ACC modulates both emotion and cognition, this
neural network interplay accounts for the fact that, as incidents of work overload,
emotional exhaustion, and job burnout increase, a greater focus upon emotional control
at work is demanded of the provider. With work overload, the thinking and cognitive
decision-making of the provider are adversely affected, and errors and adverse events
that have a negative impact on patients and providers alike may increasingly occur.

Affect
Affect is the outward, observable manifestation of an individual’s emotional feelings
(Panksepp, 1998) and is the outward reflection of internal mood states and
dispositional traits (Carver et al., 2000; Schutte et al., 2003). Affect has been measured
and reported as varying levels of positive, negative, and neutral feelings (Cacioppo
et al., 1997; Davidson et al., 2000; Lucas and Diener, 2003; Tellegen et al., 1999; Watson The motivation
et al., 1988). Gray (1990) found that engagement in positive “approach” behaviors to care
parallels the experience of positive feelings, and that motivational inhibition or
“withdrawal” behavior is linked to negative feelings (Gray, 1990) In general, positive
affect (PA) is reflected in acute emotional states of positivity, and in periodic moods
and long-term dispositions embodying feelings such as happiness, joy, excitement, and
energy (Lucas and Diener, 2003). Negative affect (NA) encompasses those feelings, 21
moods, or dispositions reflecting sadness, anxiety, fear, and anger (Lucas and Diener,
2003).
In neuro-scientific research studies, positive affect has been correlated with the
enhancement of cognition and cognitive decision-making, including creativity, episodic
and working memory, problem-solving, verbal fluency, coping with negative events,
executive functioning, and feelings of self-efficacy (Ashby et al., 1998; Ashby et al.,
1999; Aspinwall and Taylor, 1997; Baron, 1990; Chen et al., 2001; Corbetta et al., 1991;
Estrada et al., 1994, 1997; Hirt et al., 1996; Isen, 1999; Isen et al., 1991; Lucas and Diener,
2003). In contrast, negative affect has been linked to the enhancement of the following
cognitive processes: Interpretation of potential danger, avoidance of aversive stimuli,
and executive control functions. Negative affect has also been associated with
increased levels of behavioral inhibition, and switching of attention, sometimes
interpreted as “vigilance” or attention to detail; as well as attention to dull, routine, or
unpleasant tasks (Diener, et al., 1995; Lucas and Diener, 2003; Phillips et al., 2002;
Rusting, 2001; Tomarken and Keener, 1998; Watson, et al., 1999).
In individuals who tend toward negative affectivity, however, environmental
stressors may be perceived as more threatening and the individual may consistently
believe he or she cannot overcome problems (Suls, 2001). Inclined to focus on work
stressors, problem-solving may be attempted, but the consistent influence of negative
affect creates negative expectations, potentially causing the individual to give up hope,
creating a self-perpetuating, neurotic cycle (Forgas, 2001; Suls, 2001). People with high
negative affectivity are found to exhibit affective inertia, reactivity, and increased
perceived exposure to problems, and they exaggerate the impact of repeated problems
(Diener et al., 1999; Forgas, 2001; Suls, 2001). Thus, although negative affect is thought
to influence cognition in beneficial ways that support attention to detail and vigilant,
watchful behaviors, consistently high negative affectivity leads to avoidance behaviors
that undermine the individual’s emotional and social well-being (Suls, 2001).
The authors posit that increased self-awareness and self-reflection support a more
healthy integration and behavioral self-regulation of these motivational states and
traits at work, in turn supporting optimal thinking and problem-solving on behalf of
patients in the nurses’ care. Perhaps assisting nurses to become more self-reflective,
that is, to be more self-aware and to self-observe their affect and mood, would empower
nurses to achieve a mindful balance of emotions and affect in order to promote optimal
clinical reasoning and problem-solving while functioning within complex health care
work environments.

Personality
In the past decade, several studies have linked affect and mood states to personality
(Barrick et al., 2003; Carver et al., 2000; Depue and Collins, 1999; Schutte et al., 2003;
Erez and Isen, 2002; Rusting, 2001; Suls, 2001) and motivation (et al., 2003; Barrick and
JHOM Ryan, 2003; Carver et al. 2000; Depue and Collins, 1999; Erez and Isen, 2002; Fiedler,
20,1 2001; Forgas, 2001; Rusting, 2001). In these studies, the structure of personality has
generally been characterized within the Five Factor Model of Personality (Goldberg,
1990; John, 1999). The “Big Five” dimensions are reflected in the dispositions of
extraversion (or surgency), neuroticism (or emotional stability), agreeableness,
conscientiousness (based in value system), and openness to experience (creativity)
22 (Goldberg, 1990; John, 1999; McCrae and Costa, 1999). In the aforementioned studies,
the personality trait of extraversion was linked empirically to approach behaviors,
incentive motivation, positive mood, and positive affect, whereas neuroticism was
linked to negative mood, negative affect, and inhibited or withdrawn-type behaviors.
A recent meta-analysis of motivation and job performance links work motivation to
the Big Five personality dimensions (Barrick et al., 2001). The factors of
conscientiousness (based in one’s values), and emotional stability (low neuroticism,
or low tendency toward worry and anxiety), were the two primary personality traits
that predicted overall job performance across nearly all jobs (Barrick et al., 2001).
Based upon this synthesis, Barrick et al. (2001) proposed a social cognitive model of
motivational behaviors at work. The model depicts conscientiousness and emotional
stability as the primary base from which behavioral intentions and motives arise
(Barrick et al., 2001). These two personality traits in turn drive
“accomplishment-striving” or the motivation to achieve goals at work.
Accomplishment-striving is also influenced by an individual’s agreeableness and
extraversion when work teams and or work with a social component are involved
(Barrick et al., 2003; Barrick et al., 2001). Thus, for nurses working in social human
caring contexts, empirical evidence suggests that four of the five dimensions of the Big
Five personality traits – emotional stability, conscientiousness, agreeableness, and
extraversion – need consideration as one plans and designs organizational work
conditions to support nurses’ work motivation.

Cognitive style
Becoming more aware of one’s cognitive decision-making style may also influence
self-reflection and self-regulated motivation to care. As a trait, a person’s cognitive
style refers to an individual’s preferred way of thinking and problem-solving (Kirton,
2000, 2003). Cognitive style is stable over time and across situations and has been
associated with personality (Buttner et al., 1999; Elder, 1989; Gelade, 2002; Goldsmith,
1984; Goldsmith and Matherly, 1987; Kirton, 2000, 2003; Wunderly, 1996).
Kirton’s (2000, 2003) theory of cognitive style characterizes cognitive
decision-making and creativity across a unitary continuum from adaptation to
innovation. Individuals who tend to be more adaptive in style concentrate on
increasing efficiency and conforming to established rules and authority (Kirton, 2000,
2003). These individuals prefer implementing change using existing paradigms. Those
who tend to be “adaptive” prefer working on one task at a time and are less tolerant of
ambiguity (Kirton, 2000, 2003).
Persons who are innovative in cognitive style tend to generate large numbers of new
ideas, operate well in a crisis, engage in more risk-taking, and are “multi-taskers”.
Innovators adapt more readily to radical change and are better able to generate new
paradigms (Kirton, 2000, 2003). As an occupational population, most nurses fall on the
adaptive end of the adaptation-innovation continuum (Kirton, 2000, 2003). Validation
and correlation of the adaptive and innovative styles to particular personality traits or The motivation
dimensions have been demonstrated in relation to four other behavioral scales (MAS, to care
MBTI, PANAS, “Big Five” and Eysenck and Eysenck Extraversion Scale) (Bagozzi
and Foxall, 1995; Kirton et al., 1995).
Linking cognitive style theory with personality, “innovator”’ are associated with the
traits of risk-taking and sensation-seeking (Goldsmith, 1984), extraversion, openness to
experience, conscientiousness (Gelade, 2002), and optimism (Wunderly, 1996). 23
“Adaptors” are linked with lower self-esteem (Buttner et al., 1987) and lower
sensing-intuition (Goldsmith, 1984). In relation to states of being, individuals who are
more adaptive in nature have reported significantly higher state anxiety in the context
of change within an organization (Elder, 1989). Although frequently tested, cognitive
style has not been associated with the traits of neuroticism, emotional lability, or trait
anxiety (Kirton, 2003).
Individuals who are consistently required to work “outside” their characteristic
thinking and problem-solving style must engage in coping behaviors to do so (Kirton,
2000). If these coping behaviors are required for long periods at work, stress increases
and, in turn, a risk for work dissatisfaction, lack of motivation, and the projected
potential for error (Kirton, 2000, 2003). Stress that cannot be managed by other means
may lead employees to leave a position or even a profession (Kirton, 2000, 2003)
Individuals of differing styles may also have a difficult time working together on
teams, unless assisted in becoming more aware of the opposite problem-solving style
preferences and approaches to cognitive decision-making (Kirton, 2000, 2003; Moody
et al., 2005).
Acknowledging the far-reaching implications of affect, mood, personality, cognitive
style, and cognitive decision-making in relation to motivation and the potential impact
upon nurses and patient care delivery is important. Creating work environments that
support manageable patient workloads and levels of complexity is likely to decrease
nurses’ emotional stress levels and enhance affective states and traits. Positive affect
influences work motivation and nurses’ capacity to effectively engage in
knowledge-based decision-making on behalf of patients. Supporting nurses and
nursing work teams in becoming more aware of their diversity in relation to affect,
personality, and cognitive styles may enhance teamwork and open communication in
solving complex problems at work.
In relation to cognitive and emotionally based motivational factors influencing
work performance, self-determination, self-efficacy, and self-esteem are next discussed
since they also serve to support or undermine individual competence at work. These
individual differences help drive state and trait level human feelings that sustain
meaning and purpose as nurses engage human caring work in increasingly complex
environments.

Self-determination and motivation

Self-Determination Theory (SDT) is a theory of human motivation and personality that
suggests people who think about their actions reflectively and subsequently engage in
those actions with a full sense of choice, are self-determining personality types (Deci
and Ryan, 1985). Motivation on the polar opposites of this theoretical continuum
extends from amotivation (choosing not to act) to fully extrinsic motivation (acting
principally from external sources and perceptions). The amotivated individual feels a
JHOM lack of intent, lack of valuing, and lack of perceived control, generating feelings of
20,1 incompetence at work. The extrinsically motivated individual responds principally to
external perceptions of reward and punishment and ego involvement, leading to
feelings of material, but not intrinsic, reward at work. At the center of this continuum is
the intrinsically motivated individual who manifests “authentic” motivation. This type
of motivation is most desirable in relation to well-being and is based upon motive
24 congruence and synthesis with one’s self and one’s interests, enjoyment, satisfaction,
and life purpose (Ryan and Deci., 2000). According to theorists Ryan and Deci (2000),
the human motivation to act stems from our basic psychological needs for autonomy,
interpersonal relatedness, and competence in social contexts.
Motivation theorists Thomas (2000) and Locke and Latham (2004) also emphasize
the primary role that freedom of thought and choice play in supporting individual
intrinsic motivation. Notions of autonomy, empowerment, interpersonal relatedness,
and competence that are congruent with nurses’ purpose of human caring and their
professional ethical value system serve to sustain nurses’ intrinsic motivation at work.
Such self-determination is likely influenced by individual differences in self-efficacy
and self-esteem.

Self-efficacy and motivation

Self-efficacy is a central part of an individual’s exercise of control. Perceived
self-efficacy is a person’s belief in his or her own capacity to “organize and
execute the courses of action required to produce a given attainment” (Bandura,
1997, p. 3). Belief in one’s self-efficacy is viewed as an integral component to
behavioral state motivation. Self-efficacy affects one’s effort, persistence, and task
strategies related to goal-setting and goal attainment at work (Locke, 1997).
There are four sources of perceived self-efficacy:
(1) enactive mastery – we learn by doing, moving from simple to complex tasks;
(2) vicarious experience – comparison of self-performance to another’s performance
of a similar task;
(3) verbal persuasion – verbal encouragement of, and demonstrative faith in,
another’s capabilities; and
(4) physiological and affective states – lower stress levels and enhanced physical
states foster feelings of self-efficacy (Bandura, 1997).

Belief in self-efficacy supports increases in confidence related to reaching higher levels

of work performance (Locke et al., 1986). Success related to self-efficacy depends on
another important individual difference – that of self-esteem.

Self-esteem and motivation

Self-esteem is the degree to which individuals value themselves – it is the composite of
feelings of self-worth accumulated over time (Thomas, 2004). Self-esteem is determined
by both internal messages and external appraisals of the individual by others
(Thomas, 2004). Research has shown that the self-esteem of females is typically lower
than that of males (Freiberg, 1991; Brown and Gilligan, 1992; Gallop et al., 1995). Thus,
in a predominantly female profession, it is particularly important to be cognizant of the
impact of self-esteem upon motivation at work.
 Concerning areas affecting self-esteem that have the potential for undermining The motivation
motivation at work, nurses have reported feeling inadequately prepared for the social, to care
interpersonal, and emotional demands of the profession (Henderson, 2001; McQueen,
2004; Secker et al., 1999). The impact of nurses’ reported stress levels at work is well
documented, and is associated with decreases in job satisfaction and morale (Aiken
et al., 2001; Alderman et al., 1996; Corey-Lisle et al., 1999; Nolan et al., 1999; Nolan et al.,
1995; Strachota et al. 2003). In one recent study, high levels of stress at work for nurses 25
contributed to low self-esteem, emotional exhaustion, depersonalization burnout, and
recognition of mental illness-type symptoms (Edwards et al., 2000).
In a ten year longitudinal study, strong self-esteem along with a sense of
competence reportedly helped prevent worker “burnout” (Kalimo et al., 2003, p. 119).
Strong self-esteem and perceived competence are individual characteristics that
support work motivation and retention. These variables can be enhanced by
organizational influences of support from superiors, work team cooperation, and work
appreciation (Kalimo et al., 2003).
The synthesis of evidence and theories to date suggests that the motivation to care
is enhanced through meaning making and purpose management. The motivation to
care requires attention to issues of individual cognitive style and motivational affective
states and personality traits. These factors are managed and regulated by a person’s
underlying feelings of self-determination, efficacy, esteem and competence. Higher
levels of self-esteem are associated with more authentic intrinsic motivation;
motivation is driven by values internal to the self, rather than by external influences
(Ryan and Deci, 2000). Supporting authentic and intrinsic motivation lead to enhanced
work performance, persistence, and creativity (Deci and Ryan, 1991; Sheldon et al.,
1997); higher vitality (Nix et al., 1999); and enhanced subjective well-being in one’s
personal and professional life (Ryan et al., 1995). The research and theory reviewed and
integrated thus far leads to the development of a meta-theory for the motivation to care
in professional nursing work.

Towards a theory of motivation to care for professional nursing work

Both Herzberg’s (1968) and Hackman and Oldham’s (1980) theories have been used to
explain motivation in health care contexts and nursing work. Significant correlations
among nurses’ work motivation, nurses’ internal psychological states, and external job
characteristics such as autonomy, work conditions, quality of supervision, and
interpersonal relations have been reported for staff nurses (Edgar, 1999; Janssen et al.,
1999; Joshua-Amadi, 2002). Nurses’ work motivation is significantly and positively
related to both the quality of job content and to the personal meaning and knowing
represented by the work characteristics studied (Edgar, 1999; Janssen et al. 1999;
Joshua-Amadi, 2002).

Unique organizational attributes and nurses’ work motivation

In one study, the primary motivational drivers in relation to nurses’ work included
autonomy, job significance, and the meaningfulness of the work (Edgar, 1999). Edgar’s
(1999) application of the Job Characteristics Model (JCM) (Hackman and Oldham, 1980)
documented specific relationships among the JCM and the Job Diagnostic Survey
variables. Analysis of the results revealed significantly low nurse scores in
JHOM meaningfulness of work, task identity, skill variety, job feedback, opportunities for
20,1 growth, pay, and job security.
Edgar (1999) empirically derived and added uniquely desirable, nurse-reported
work attributes of nursing care delivery to the JCM. These unique organizational
attributes found to be important to nurses’ intrinsic motivation included optimal levels
of:
26 .
time for patient care;
.
autonomy in decision making;
.
open communication; and
.
manageable levels of work complexity.

The study revealed that nurses’ work motivation was significantly related to these
attributes in complex health care system contexts.

Internal psychological states and nurses’ work motivation

These results illustrate the influence of important contextual variables (time,
autonomy, communication, and complexity) that influence nurses’ intrinsic motivation
in health care work environments. Evidence further suggests that nurses’ intrinsic
motivation to manage the unique attributes of nursing care delivery is mediated by
certain internal psychological states. Nurses who report successfully engaging the
motivation to care are supported in manifesting internal psychological states at work
in relation to meaning and knowing, including the meaningfulness of the work,
knowledge of responsibility for the results of the work, and knowledge of outcomes of
the work, in relation to patient care (Edgar, 1999).
Additional support for the association between nurses’ internal psychological states
and nurses’ work motivation comes from the work of Janssen et al. (1999) and
Joshua-Amadi (2002). These studies suggest that nurses’ work motivation is
significantly and negatively influenced by high levels of emotional exhaustion, work
overload, lack of appreciation, lack of social support, personal isolation, unmet career
expectations, and perceived decline in patient care (Janssen et al., 1999; Joshua-Amadi,
2002). It is evident that intrinsic work motivation for nurses is associated with the
meaningfulness of the work and work conditions in health care contexts. Such a
conclusion is also supported by research using motivated reasoning and social
accounts theory.

The psychological contract and nurses’ work motivation

Motivated reasoning and social accounts theory emphasize the importance of the
“psychological contract” for nurses at work. Psychological contracts are defined as
relational or transactional, and represent the level and type of obligation perceived
between the employer and the employee in an organization. A “relational”
psychological contract develops from feelings of mutual obligation to support one
another’s interests at work, fostering mutual trust, commitment, and loyalty for the
involved parties (Rousseau and Tijorwala, 1999).
In contrast, a “transactional” psychological contract is driven by concrete
contractual or monetary obligations between employer and employee (Rousseau and
Tijorwala, 1999). In two separate studies of staff nurses in hospital settings, the
presence of conditions supporting a relational psychological contract positively The motivation
influenced nurses’ work motivation (Joshua-Amadi, 2002; Rousseau and Tijorwala, to care
1999). Organizational leaders and managers are beginning to realize that, if the work is
not congruent with an individual’s life purpose and value system, that person is
motivated to leave and find work elsewhere with an organization that will support his
or her purpose-driven values (Thomas, 2000).
The motivated reasoning of individuals in organizations is also influenced by the 27
level of trust employees have vested in leadership. Such trust involves active
information processing and engagement in choices, based upon belief in the legitimacy,
functionality, and constructiveness of organizational leadership’s decision-making
processes (Rousseau and Tijorwala, 1999). Nurses’ intrinsic motivation to work is
enhanced if high levels of trust have been established between employer and employee
(Rousseau and Tijorwala, 1999). This trust promotes nurses’ work motivation, even in
the face of significant organizational change and restructuring (Rousseau and
Tijorwala, 1999). Both relational psychological contracts and high levels of trust
support positive intrinsic motivation of staff nurses in health care settings
(Joshua-Amadi, 2002; Rousseau and Tijorwala, 1999). Such research evidence
provides data for theory building and evidence-based leadership and management
principles for practice.
Work conditions important to nurses and identified as moderators of nurses’ work
motivation are time, autonomy, communication, and complexity. Attention to these
conditions sustains nurses’ meaning-making and values-based human caring in the
organization. In the empirical literature on nurses’ work motivation, evidence suggests
multiple internal and external organizational factors positively influence nurses’ work
motivation. These factors appear to sustain nurses’ internal psychological states of
meaning and knowing in relation to patients in the nurse’s care. Such psychological
states enhance the meaningfulness of the work and sustain relational psychological
contracts between nurses, patients and organizational leadership in the health care
setting, in turn enhancing the motivation to care.

Professional competence and nurses’ work motivation

Glen (1998, p. 41) suggests that “nursing as an art” is the fullest expression of quality
nursing care. “The nurse-patient relationship happens through the performance of
duties that are attendant on special needs. This performance enshrines caring. Indeed,
the attention to special needs is caring. Competence involves the development of
emotional and motivational states that are appropriate to the nursing task. Hence,
personal qualities [of caring through attention to special needs] can justifiably be
viewed as a fundamental source of nursing competence.”.
According to Glen (1998), nurses need to examine and become more consciously
aware of their emotional and motivational states in order to support competence and
caring in nursing work. Glen (1998) acknowledges that nurses may sometimes be
unaware of their own motivational and emotional states. Such limited emotional
intelligence and or motivational unconsciousness impacts nurse performance,
rendering the nurse vulnerable and potentially powerless to act or to make optimal
decisions (Glen, 1998; McQueen, 2004). In contrast, individuals with high emotional
intelligence and motivational consciousness use these states as a source of personal
JHOM and professional power to intentionally respond to the complex work demands placed
20,1 upon them (Glen, 1998; Goleman, 1998; McQueen, 2004).
Glen (1998, p. 39) links the motivational and emotional tendencies of nurses at work
to “skill knowledge.”. Intelligent skill knowledge is viewed as essential to nurses’
values-based caring and competence. Intelligent skill knowledge involves the nurse
perceiving and actively thinking about care rendered to a person, demonstrating the
28 ability of discernment toward intelligent action. Conversely, the possession of
“habitual skill knowledge. . .enables a person to perform, unreflectively, certain
necessary routines.” (Glen, 1998, p. 39).

Situational aspects and nurses’ work motivation

Irrespective of the conscious or unconscious motivational-emotional aspects of nurses’
work, motivational conditions are also influenced by critical incidents and situational
aspects of the work environment (Herzberg, 1980, cited in Cubbon, 2000). Situational
variables at work influence work motivation given organizational contexts, and are
reflected in the nurse-environment dynamic (Cubbon, 2000). Within this dynamic,
incidents at work influence an individual’s motivational states when perceived as
“good” or “bad” (Cubbon, 2000). In the bad situational state, an individual may incur
decreased motivation, or even be motivated to leave the organization, whereas good
situations positively influence an individual’s work satisfaction (Herzberg, 1980, cited
in Cubbon, 2000) as well as commitment and intention to stay.
State motivation of nurses is also influenced by human contextual environments
and relationship variables among individuals present in the environment – such as
variables in the nurse-patient relationship or work team relations (Cubbon, 2000).
Within the nurse-patient relationship, state motivation most likely stems from the
meaningfulness of work, knowledge of responsibility for the results of the work, and
knowledge of the outcomes of the work (Edgar, 1999). Theoretically, a nurse’s
internalized meaning and knowing about the value of, responsibility for, and outcomes
of the work are likely to influence the nurse’s state motivation.
In summary, research and theory to date suggests that nurses’ work motivation is
enhanced through meaning-making that supports moral practice and the ethic of
caring. Autonomy in nursing practice contributes to a sense of personal power and
competence that empowers application of a nurses’ intelligent skill knowledge as he or
she engages in professional nursing work. Both conscientiousness and emotional
stability are reported to be the primary base from which behavioral intentions and
motives arise (Barrick et al., 2001). These two personality traits in turn drive
“accomplishment-striving” or the motivation to achieve goals at work.
If nurses are unable to identify emotional and motivational states as they respond to
positive and negative aspects of work, they may be unaware of how these factors
influence their assessment of the meaningfulness of work, their professional
competence, or the motivation to care. A lack of motivation on the part of
individuals results in apathy, poor health and well-being, and a sense of powerlessness
(Fletcher, 1999). A lack of motivation to care is likely to lead to less desirable outcomes
for patients in the nurse’s care. Based on research and theory the authors propose the
following model of the motivation to care for professional nursing work.
The model is presented in Figure 1. The primary goal in nursing is proposed to be
human caring through competence. A nurse’s perceptions of meaning and knowing
 The motivation
to care

29

Figure 1.
Propositional statements
for the meta-theoretical
model: motivation to care
for professional nursing
work
JHOM
20,1

30

Figure 1.
 The motivation
to care

31

Figure 1.

about patients in his or her care create satisfactory value states of being for the nurse.
Satisfactory value states, in turn, support nurses’ caring-competent behaviors at work.
Congruency of work purpose, process, and progress with one’s values and beliefs and
work goals is important. Congruence and alignment of personal and professional goals
support purpose-driven employee-employer partnerships in modern-day
organizational work settings (Thomas, 2000).
Caring-competence connects nurse to patient effectively through meaning and
knowing. Specifically, through a nurse’s perceptions of work meaningfulness,
knowledge of responsibility for results of the work, and knowledge of the outcomes of
the work, positive motivational states are created and maintained. The nurse’s
professional ethical code also supports his or her intrinsic motivation to care in a
competent manner through attention, awareness, and application of intelligent skill
knowledge on behalf of patients.
Values-based intrinsic motivation potentiates positive behavioral response and
makes nurses more likely to interact with patients in caring and competent ways. As
nurses become more conscious and intentional in recognizing their own motivational
JHOM factors, they are able to assert their professional power and autonomy. Assertion of
20,1 professional nursing power and autonomy heightens the quality and safety of the care
that nurses give in complex health care environments.
Environmental conditions promote nurses’ work motivation, including adequate
amounts of time for patient care, optimal levels of autonomy and communication, and
manageable levels of complexity in the health care setting. These work conditions
32 support and influence the psychological contracts that develop between nurses and
organizational leadership. These factors affect work contexts and a nurse’s capacity for
meaning and knowing about the work. Meaning and knowing influence nurses’
intrinsic motivation and, in turn the propensity for caring and competent behaviors.
Careful and intentional attention to the development of a relational psychological
contract supports nurses’ work conditions in health care, especially on the nursing
ward or unit where the majority of nurse-patient care and interaction takes place.
Relational contracts are most likely to positively influence nurses’ intrinsic motivation,
caring, and competence, and are likely, in turn, to have a positive effect on patient
health status and patient health outcomes.

Preliminary testing of the model

The authors recently tested selected relationships in this theoretical model in a study of
nurses’ behavioral motivation and cognitive decision-making style in relation to nurse
productivity, perceptions of safety and willingness to report medication errors on
nursing units. The study involved staff nurses (n ¼ 158) on six medical-surgical units
in two US hospitals (response rate of 85 percent) in a metropolitan health care system.
In this research study, 70 percent of nurses self-reported a relatively adaptive
cognitive style. As adaptors, these nurses preferred precise instructions, low
complexity, and working on one task at a time (Moody et al., 2005). Adaptive cognitive
style in the nurses was associated with higher levels of motivational inhibition, a
variable was predicted decreased willingness to report medication errors (Moody et al.,
2005). In addition, cognitive decision-making style was correlated with measures of
behavioral motivation. Adaptors reported lower motivational drive and worked more
hours on the nursing units. In the months that fewer nurses’ work hours were put into
direct, hands-on patient care on these units, reflecting a higher patient workload per
nurse, a greater number of errors were reported by the nurses on the units (Moody et al.,
2005).
Nurses in this study perceived significant problems with health care provider
teamwork between hospital units. A major concern related to teamwork during
unit-patient “hand-offs and transitions”, reflecting perceptions of poor communication
and collaboration across nursing units (Moody et al., 2005). In contrast, in multiple
regression analysis, factors that predicted enhanced nurse productivity and
perceptions of patient safety on the units included nurses’ ability to communicate
and collaborate effectively with one another, the presence of positive within-unit
teamwork, and proactive, appreciative leadership on the nursing unit (Moody et al.,
2005).
Overall, a higher level of direct care hours worked by the nurse on the units was
associated with lower intrinsic motivational drive, decreased response to
internal/external rewards, and decreased manifestation of approach behaviors in his
or her work (Moody et al., 2005). Higher levels of nurses’ motivational inhibition were
associated with less willingness to report error. Overall, in both hospitals, nurses The motivation
perceived a highly punitive environment that significantly and negatively affected to care
their frequency of error reporting (Moody et al., 2005).
This initial evidence prompts the following observations:
.
The establishment of desirable work conditions related to time, autonomy,
communication, and complexity – work conditions that may cause worry or
stress and thus undermine intrinsic motivation, an adaptive cognitive style, and 33
safe nursing practice – are of great import to planning how to sustain nurses’
work motivation to maintain safe, high quality patient care in health care
systems.
.
An administrative focus upon ethical values of nurses from a nurturing
organizational stance would support nurses in relation to the emotionally-based,
motivational “approach” behaviors needed on behalf of patients in the nurses’
care.
.
An open, non-blame, non-punitive reporting environment would support nurses
in openly discussing and reporting error.
.
Recognition and monitoring of, as well as proactive responses to, nurses’ levels of
stress and motivation in relation to manageable patient workloads need to be
considered in order to retain and support nurses in the human caring work that
we expect them to perform competently each day.

Theory-based principles to support nurses’ work motivation

“We live in cultures in the same way that fish live in water. Just as fish are said to
discover water last, our cultural ways are often invisible to us” (Bolman and Deal, 2004,
p. 240). How do we as leaders, managers, researchers, and educators serve to support
nurses in their work? Are our current leadership and management practices and
strategies consistently addressing intrinsic and extrinsic factors shown to influence
nurses’ work motivation? What are some new ways in which we can enhance nurses’
work environment, ultimately re-viewing, re-engaging, and renewing nurses as they
pursue their professional human caring purpose, passion, and progress?
From the outset, we have emphasized the meaning-making and interpersonal
relational reciprocity that is central to nurses’ work. Support for nurses’ ethical value
system, intrinsic and extrinsic motivational factors, and motivational states and traits
at work creates a context for consciousness-raising that in turn leads to nurses’
enhanced self-awareness and engagement in the nurse-patient relationship. An
organization’s commitment to support nurses’ work motivation might attend to
theories and practices derived from studies about motivation, affect, personality, and
individual differences, all of which influence work performance.
Acknowledging the dynamics surrounding human motivation requires sustaining
connections among individual values, purpose, and the meaningfulness of the work
(Thomas, 2000). In order to support nurses in productive knowledge work, new
practices need to be created and tested for their positive or negative impact on nurses’
knowledge work, reward incentives, and work performance (Curtin, 1995; Moody,
2004; Pesut, 2003, 2004).
The meta-theoretical framework and corresponding principles that support the
framework bring to the forefront the central ethical context of human
JHOM caring-competence that forms the basis of the nurse-patient relationship. The authors
20,1 suggest that leader/manager behaviors, cultural phenomena, and management
strategies can singularly and importantly influence nurses’ work motivation.

Leadership strategies to support nurses’ work motivation

Fostering values-based caring
34 Tables II-V present values-based, purpose-driven leadership and organizational
cultural strategies that the health care administrator or manager can introduce and
tailor to a particular hospital unit or ward to support nurses’ intrinsic motivation for
the human caring work that they do. These strategies stem from current leadership
paradigms that assume individuals seeking meaning within complex human systems
from a values-based, social citizenship point of view (Allee, 1997; Bolman and Deal,
2004; Cooperrider and Srivastva, 1999; Moody, 2005; Thomas, 2000; Weick, 2001).
Empowering behaviors by leaders serve to support self-esteem and beliefs in
self-efficacy, and to foster such motivational and emotional growth in nurses. A group
of nursing studies were conducted by Laschinger and colleagues stemming from
Kanter’s (1993) seminal work on power in organizations. In this group of studies, staff
nurses’ perceptions of empowering processes and leadership at work were associated
empirically with increases in organizational commitment (Laschinger et al., 2001;
Laschinger et al., 2000), job satisfaction (Laschinger et al., 2001), job autonomy
(Sabiston and Laschinger, 1995), perceived productivity and work effectiveness
(Laschinger and Wong, 1999; Laschinger et al., 1999), occupational mental health
(Laschinger and Havens, 1997), and decreased job burnout (Hatcher and Laschinger,
1996; Laschinger et al., 2001). Importantly, a cross-sectional analysis by gender of
responses to empowering strategies in organizations revealed no differences between
men and women (Finegan and Laschinger, 2001).
Indeed, individual and organizational resources and people that create strategies to
intentionally strengthen the nurse’s belief in his/her own self-efficacy in the
organization serve to nurture individual self-determination and self-esteem, and thus
the motivation to engage in human caring work and the motivation to care. Enhanced
self-efficacy and self-esteem are suggested to influence confident, autonomous
decision-making, and these states and traits are integral to achieving goals at work.
Implementing interventions that support an individual’s self-esteem reflects
management’s confidence in that individual being able to attain goals and perform
effectively and successfully in given situations.

Fostering high reliability

In high reliability organizations (HRO’s), proactive employees make safety a top
priority, practicing “mindful interdependence” in relating and attending to peers,
customers, and ever-changing conditions in the environment (Tables II-V) (Weick,
2001, p. 191). Mindful interdependence involves team members’ heedful attention and
heedful interrelating to one another and to the environment, interacting in synergistic
and empowering ways to meet challenges and solve problems (Weick, 2001). Built-in
checks and balances, ongoing training, and open, non-punitive error reporting systems
are hallmark components of the structure and processes of an HRO (Weick, 2001). To
replace the ideas of perfectionism, shame, and silence surrounding error and error
reporting that is characteristic of today’s health care work culture ((Maxfield et al.,
Nurses’ work Perspectives
moderator Values and purpose Individual Team Leader/manager strategies

Time Ethic of care
Competence
Meaningfulness
Efficacy
Motivational rationale:
Nurses need adequate time to contribute
values-based human caring through
application of intellectual capital,
professional skills and competencies,
along with system resources and
technology, combined with particular
patient inputs to achieve optimal
negotiated health outcomes.
Professional Collaboration Intentionally value and reward nurses’ ethical human caring
practice Data and stance, intellectual capital, and individual and collective
Knowledge information learning.
work sharing Implement and reward direct nurse input and strategizing for
Clinical Knowledge unit staffing and staffing policy decisions.
reasoning generation Pilot-test creative uses of technology that streamline care and
Cognitive Collective improve productivity, safety, e.g. transform nurse
decision cognitive documentation through voice-activated dictation and
making decision transcription via headset. Provide hand-held PDAs to support
making decision making re: medication administration. Seek nurse input
to develop such projects.
Highlight nurses’ work through intellectual capital management
activities – e.g. show the impact of specialty certifications and
training on patient care and patient satisfaction outcomes, and
nurses’ work satisfaction and commitment outcomes. Consider
monetary reward for participation in intellectual capital
management activities.
Make nursing contributions visible through data classification
systems that underscore nurse time, educational level and
skill/competency required for nurse interventions and desired
outcomes (e.g. NIC and NOC).
Create and sustain communities of practice to support a vital
learning organization. Reward individuals who participate. This
serves to maintain and grow the intellectual capital “stock” of
the organization and fosters teamwork, communication and
social support while taking advantage of the potential for
valuable external inputs of knowledge.
Demonstrate and reward the fact that nurses’ intellectual capital
stock is contributing to the financial performance of the
organization.

Evidence-based

motivation
to care
The motivation

leadership principles to
support nurses’ work
35

Table II.
 36
20,1
JHOM

Table III.

motivation
Evidence-based

support nurses’ work

leadership principles to
Nurses’ work Perspectives
moderator Values and purpose Individual Team Leader/manager strategies

Autonomy Ethic of care
Competence
Empowerment
Self-determination
Motivational rationale:
Nurses need to be able to act with
authority to make knowledge-based
ethical, clinical, and quality decisions on
behalf of their individual work, the
collective team’s work and for patients in
their care, within the professional scope
of practice.
Professional Collaboration Prepare nurses for autonomy by teaching and modeling benefits
practice Efficacy of shared power structures at work. Establish, direct, nurture
Knowledge Quality and mentor nurses’ access to opportunities, resources, support
work Safety and information, to sustain achievement of personal and
Clinical professional, individual and collective goals.
reasoning Implement and reward nurse input into management decisions
Self-efficacy impacting policy, resources, quality, safety, and patient care
Self-esteem issues.
Implement and reward nurse input into type of nursing care
delivery model utilized in the patient care setting.
Recognize and reward individual and collective goal
accomplishments.
Create visible, tangible processes and benchmarks to support
employee and team/unit accountability for the work and work
outcomes.
Provide either internal and or external coaching for innovative
performance, mentoring in particular those that are new
employees, but also to help renew veteran employees.
Express confidence and admiration and appreciation of high
performance; provide nurses tangible, desirable rewards for
achievements at the individual, team, and hospital levels.
Allow autonomy from bureaucratic constraints in the system
that hinder optimal patient outcomes by impacting timely and
effective delivery of high quality care at each step of care.
Nurses’ work
moderator Values and purpose
Communication Ethic of care
Competence
Meaningfulness
Social support
Motivational rationale:
Open, clear, consistent,
collegial communication
among health care
providers is crucial to
moving away from
professional “silos” and
perfectionism, to
creating a non-blame
safety culture, thus
positively impacting the
delivery of safe, high
quality care on behalf of
patients, families, and
the community-at-large.
Evidence-based
motivation
leadership principles to
support nurses’ work
Table IV.
Perspectives
Individual Team Leader/manager strategies
Professional practice Collaboration General strategies
Knowledge work Group Role-model open, respectful, collegial communication. Even with
Clinical reasoning cohesion shared governance and empowering organizational structures –
Psychological contract Data and values, beliefs, attitudes are communicated from the top-down.
Affect-mood-personality information Provide learning opportunities to support individual and team
Cognitive style sharing awareness of collegial communication, cognitive style, and conflict
Knowledge management skills for all levels and providers in the organization.
generation Empirical evidence shows that the quality of provider relationships
Collective impacts quality of care.
decision Embrace conflict. Conflict generates the creative tensions that are
making needed and that can be harnessed among individuals with differing
perspectives to solve complex problems.
Empower direct nurse input into unit/team interviewing and hiring
processes and decisions so that group cohesion is supported.
Foster what Weick (2001) calls “mindfulness”: learning attention to
care in relating to others, and giving close attention to the
unexpected.
Non-punitive error reporting
Establish confidential or anonymous, uniform, concise
documentation and processes for error reporting across all
providers.
Create a non-blame environment and an open, relational,
empowering approach on the unit when dealing with provider
error.
Use non-blame language such as “variance” for provider error.
Openly and collegially share and discuss learning and/or root cause
analyses from variances, incidents or sentinel events that occur.
Engage frequent nurse-led “morbidity and mortality” meetings on
units related to individual, team, and system contributions to
adverse events.
to care
The motivation
37

Table V.
motivation
Evidence-based
support nurses’ work
leadership principles to
Nurses’ work
moderator Values and purpose
Complexity Ethic of care
Competence
Meaningfulness
Relationships
Efficacy
Motivational rationale:
System complexity requires
cognitively demanding
problem-solving and productive
behaviors in the context of
unpredictability, while
maintaining a human caring
practice. Make explicit the ethic of
care while promoting productive
interpersonal behaviors, and
improved cognitive decision
making, to promote quality care
delivery and error prevention.
38
20,1
JHOM
Perspectives
Individual Team Leader/manager strategies
Knowledge work Collaboration Consider how stress, overwork, and hostile or punitive environments
Clinical reasoning Efficacy contribute to work conditions that are currently found in many
Cognitive decision Quality health care systems. Take steps to mitigate these factors in your
making Safety organization.
Cognitive style Adopt practices of a high reliability organization (HRO):
Affect-mood-personality 1. Make safety a top priority and consistently communicate this goal.
2. Make sure that a team has diversity of talent, style, and
experience.
3. Teach and encourage mindful interdependence:
a. Heedful, discriminating attention to detail
b. Heedful attention and care in interrelating
c. Attention to, and anticipation of, the unexpected.
4. Design “redundancy” or checks and balances into the system.
5. Train personnel continuously.
6. Establish non-punitive, open reporting and learning from errors.
7. Nurture the collective “mind” that is located among members of
the team and the quality of their interrelating.
8. Enlist change agents internal or external to the organization to
promote buy-in and engagement of positive HRO characteristics.
9. Incorporate practices of “the HRO promotes a safety culture”.
Understand and communicate impact of affect and mood on decision
making, teamwork, quality and productivity. Positive affect and
mood are associated with enhancements in clinical problem solving,
teamwork, productivity, health, and retention rates of employees,
and more positive patient perceptions of care quality and
satisfaction with care.
Nurture, sustain nurses in values-based ethic of caring practice by
keeping focus on the “simplexities” among the complexity of work:
The human caring context of nurse-patient relationship, nurse as
educator, nurse as counselor, nurse as healer for the patient, family,
community.
2005; Pizzi et al., 2004), the safety culture inherent in an HRO encourages open The motivation
discussion and analysis of error causes and possible solutions. HRO’s create to care
environments in which a powerful sharing of information and generation of new
knowledge is integral to organizational learning in the contexts of safety and quality
(Helmreich, 2000; Weick, 2001).

Fostering mentoring 39
Consistent and nurturing direction on behalf of nursing management and leadership
needs to be implemented in order to guide nurses toward higher levels of professional
growth and development in their roles as caring, autonomous practitioners (McQueen,
2004). Mentoring nurses along the path of professional self-actualization will help
develop and foster the individual and collective sense of power and intrinsic motivation
on behalf of patients in their care. The payoff for consistent nurturing of the work
group will constitute a shift to a healthier work culture that is proactively responsive to
patient and work demands; when necessary, goes beyond following the rules to
accomplish quality care outcomes; and can adapt and respond more readily and
creatively to ongoing change in the environment (Wolf, 2005).

Conclusions
Purpose supports motivation at work, as well as in one’s personal and professional life
(Thomas, 2000). Purpose manifests itself on two levels. First, there is a more literal,
state intention to purpose, the simple purpose of accomplishing the task at hand. Both
contemporary and classic theories of motivation support this view (Hackman and
Oldham, 1980; Herzberg, 1980; Locke and Latham, 2004). However, in a broader sense,
there is also human trait purpose akin to mission that arises more symbolically to
support and guide one’s motivational behaviors in meta- rather than literal contexts
(Bolman and Deal, 2004; Thomas, 2000). This higher, more complex purpose is
sustained by deeply held values that connect to the perceived meaning of one’s life and
work ((Bolman and Deal, 2004; Pesut, 2003; Thomas, 2000). Such higher purpose
supports and guides motivational behavior in work and personal contexts (Locke and
Latham, 2004; Thomas, 2000). If work purpose is aligned with the implicit meaning of
the work, employees are more inclined to commit to the organization and trust in the
legitimacy of management to support purposeful work that is congruent with their
own values, even in the context of uncertainty and change (Rousseau and Tijorwala,
1999). Purpose is revealed through reflection.
Perhaps it is purpose management that makes the connection between individual
needs and ethical values in the context of work. The authors posit that “work purpose
backed by a value system that is meaningful to the employee is a key driver of the
motivation to care in human health care contexts”. The motivation to physically,
emotionally, and psychosocially care for other persons in one’s work serves to evoke
purpose and meaning. As Locke and Latham (2004) point out, human motivation starts
with needs, but how work values grow out of human needs has not been empirically
studied. This work suggests that the desire for meta-level purpose in life and work
supports the human need nested in the motivation to care.
Individual need for meaningfulness supports the nurses’ ethic of care, a prerequisite
to the nurse moving toward engagement of caring and competent behaviors in daily
professional practice (Edgar, 1999; Glen, 1998; Janssen et al., 1999). The health care
JHOM administrator’s incorporation of nurses’ ethical value system at work nurtures nurses’
20,1 internal psychological states, the lens through which work contexts and human caring
are viewed (Edgar, 1999). Thus, an organization that explicitly and consistently
encourages and incorporates nurses’ professional ethical value system and conscious
reflective attention to this value system contributes necessary meaning and
professional purpose management that support nurses’ intrinsic motivation at work
40 (Edgar, 1999; Janssen et al., 1999; Joshua-Amadi, 2002; Glen, 1998). As we have seen,
professional purpose management and meaning-making are also likely influenced by
individual differences and state and trait variations in cognition, personality,
self-esteem, and self-efficacy, affecting individual mindfulness and reflective skills.
Individual and collective human performance factors need to be taken into
consideration related to nurses’ motivation to care and to their professional nursing
work.
Holistic, person-centered leadership theories that explain and support values-based
work cultures are needed to support nurses in the human caring work that they do
within the context of complexity (Allee, 1997, 2003; Bolman and Deal, 2004;
Cooperrider and Srivastva, 1999; Moody, 2005; Thomas, 2000; Weick, 2001, 2002). The
complexity of work has brought organizations back to the basic concepts of human
purpose and meaning. When what we value is aligned with and supported at work, the
work becomes more meaningful to us. We can thus pursue this purpose management
and contribute to the greater good in the organizational and societal contexts and
networks where we live and work (Allee, 2003; Pesut, 2003; Thomas, 2000).

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Corresponding author
Roseanne C. Moody can be contacted at: rfmoody@iupui.edu

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