MOTIVATION AND ITS EFFECT ON PERFORMANCE ON NURSES IN ARAMCO HEALTH CENTER

By: HALA ABDULHADI AL JISHI

OPEN UNIVERSITY MALAYSIA
(2009)

MOTIVATION AND ITS EFFECT ON PERFORMANCE ON NURSES IN ARAMCO HEALTH CENTER

By: HALA ABDULHADI AL JISHI

Project Paper Submitted in Partial Fulfillment of the Requirement for the Degree of Master of Business Administration Human Resources

Open University Malaysia (2009)

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ABSTRACT

This project explores the effects that motivation has on the job performance of nurses. Several need and motivation theories have been discussed in the study to clarify what might affect the motivation of nurses. The results showed that nurses who are more motivated in their jobs are more satisfied with their performance, and less likely to leave the profession, but negatively affects the performance if the nurses are de-motivated. It is also focuses on the dissatisfaction factors that cause nurses to leave the profession such as, workplace violence, workplace hazard and injuries, long working hours, effect of night shift, shortage problem, feeling under paid, unreasonable workload and lack of appreciation.

The findings from this study provide information as to what changes can made so that nurses are more motivated in their profession.

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Open University Malaysia Center for graduate studies

APPENDIX VII RESEARCH PROPOSAL APPROVAL FORM
Project Title: Motivation and Its Effect on Performance on Nurses in Aramco Health Center Name of the student: Hala Abdulhadi Al-Jishi Matriculation No.: 51060588 Director Center for Graduate Studies Open University Malaysia Dear Sir, Attached are the following documents of your evaluation and approval: Chapter 1: Introduction Chapter 2: Literature Review Chapter 3 Research Methodology Chapter 4: Data Analysis and results Chapter 5: Recommendations Chapter 6: summery and conclusion Appendixes References I have thoroughly checked my work and I'm confident that it is free from major grammatical errors, weaknesses in sentence constructions, spelling mistakes, referencing mistakes and others. I have checked with CGS Guideline for Writing Project Paper, and I'm satisfied that my project paper proposal satisfies most of its requirements. Thank you, Student Signature: _______________________

I have read the student research proposal and I'm satisfied that it is in line with the CGS Guideline for Writing Project Proposal. It is also free from major grammatical errors, sentence construction weaknesses, citation and others. Supervisor's Signature: ____________________

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Appendix IV

DECLERATION

Name: Hala Abdulhadi Al-Jishi Metric Number: 51060588

I hereby declare that this project paper is the result of my own work, except for quotations and summaries which have been fully acknowledged.

Signature: _________________

Date: ________________

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Open University Malaysia Center for graduate studies

APPENDIX VI APPLICATION TO CONDUCT RESEARCH PROJECT

PART A: STUDENT PARTICULARS

1. Name of the student: Hala Abdulhadi Al-Jishi 2. Metric Number: 51060588

PART B: PARTICULARS ABOUT THE PROJECT

1. Project Title: Motivation and Its Effect on Performance on Nurses in Aramco Health Center 2. Research Objectives: 3. Proposal Research Methods: i. Research Design ii. Research Analysis iii. Data Collection

PART C: FACULTY INPUTS 1. Topic Chosen: Acceptable/ not acceptable: ___________________ 2. Suggested Supervisor for the Student: ____________________

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Open University Malaysia Center for graduate studies

APPENDIX VII RESEARCH PROPOSAL APPROVAL FORM
Project Title: Motivation and Its Effect on Performance on Nurses in Aramco Health Center Name of the student: Hala Abdulhadi Al-Jishi Matriculation No.: 51060588 Director Center for Graduate Studies Open University Malaysia Dear Sir, Attached are the following documents of your evaluation and approval: Chapter 1: Introduction Chapter 2: Literature Review Chapter 3 Research Methodology Chapter 4: Data Analysis and results Chapter 5: Recommendations Chapter 6: summery and conclusion Appendixes References I have thoroughly checked my work and I'm confident that it is free from major grammatical errors, weaknesses in sentence constructions, spelling mistakes, referencing mistakes and others. I have checked with CGS Guideline for Writing Project Paper, and I'm satisfied that my project paper proposal satisfies most of its requirements. Thank you, Student Signature: _______________________

I have read the student research proposal and I'm satisfied that it is in line with the CGS Guideline for Writing Project Proposal. It is also free from major grammatical errors, sentence construction weaknesses, citation and others. Supervisor's Signature: ____________________

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ACKNOLWEDGMENT

I would like to express my gratitude to all those who gave me the possibility to complete this project. This work would not have been possible without the support and encouragement of my supervisor Dr. Anwar Al Jawder, under whose supervision I chose this topic and began the project. He has also assisted me in numerous ways, including offering resource books allowing me to read the needed valuable data. I cannot end without thanking my family, my parents for their endless trust, encouragement, love, and support throughout my life. I am grateful also to my husband for his constant courage and confidence that inspire me, and I have relied on throughout my time at the University. It is to them that I dedicate this work.

Hala Al Jishi

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TABLE OF CONTENT
Chapter one…………………………………………………………………………..1 1. Introduction…………………………………………………………………………2 1.1 Background of the study………………………………………………….2 1.2 Research Problem………………………………………………………...3 1.3 Objective of the study…………….……………………………………….3 1.4 Limitations………………………………………………………………….3 Chapter Two…………………………………………………………………………..4 2. Literature review…………………………………………………………………….5 2.1 Introduction……………………………………………………….………..5 2.1.1 MARS Model…………………………………………………………..5 2.1.1.1 Motivation…………………………………………………………6 2.1.1.2 Employee Ability……………………………….………………....6 2.1.1.3 Role Perception…………………………………………………..7 2.1.1.4 Significant Factors………………………………………………..7 2.2 Motivational Theories……………………………………………………..7 2.2.1 Maslow's Theory………………………………..………………….8 2.2.2 ERG Theory………………………………………………………..10 2.2.3 Tow –Factor Theory…………………………………………...….10 2.2.3.1 Hygiene Factors………………………………………………10 2.2.3.2 Motivation Factors…………………………………………….11 2.2.4 Acquired Need Theory……………………………………………13 2.2.4.1 Need for achievement……………………………….……….13 2.2.4.2 Need for affiliation…………………………………………….13 2.2.4.3 Need for power……………………………………….……….14 2.3 Comparison of the four needs theories……………………….……….15 2.4 Process Theories of Motivation………………………………….……..15 2.5 Performance………………………………………………………..…….16 2.6 How dose Motivation Affect Performance……………………….……16 2.6.1 Motivation Formula…………………………………………….……16 2.7 Why to motivate nurses…………………………………………………17 2.8 Causes of de-motivation………………………………..………….……17 2.8.1 Work place violence……………………………………………..….18 2.8.2 Work place hazards and injuries………………………………..…18 2.8.3 Long working hours ………………………………………………...19 2.8.4 Effect of night shift…………………………………………………..19 2.8.5 Shortage and turnover problem…………………………………....19 2.8.6 Feeling underpaid……………………………………………….…...20 2.8.7 Lack of appreciation………………………………………………....21 2.9 Factors Affecting Motivation and Performance..…………………..….…23 2.10 Relationship between Motivation and Performance of Nurses……….23 2.11 How employee Motivation affects Employee Performance………...…24 2.12 Types of Rewards…………………………………………………………25 2.12.1 Monetary………………………………………………………………25 2.12.2 Non- monetary…………………………………>……………………25

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Chapter Three………………………………………………………………………….26 3. Research Methodology…………………………………………………………...…27 3.1 Research Design…………………….…………………………………………..27 3.2 Research Analysis…………………….………………………………………...27 3.3 Data Collection…………………………………………………………………..27 3.4 Data Sampling……………………………………….………………………..…28

Chapter Four…………………………………………………………………………....34 4 Data Analysis and Results..........................................................................….....34 Chapter Five………………………………………..……………………………………53 5. Discussion and Recommendation…………………………………………………..53 5.1Discussion…………………………………………………………………….54 5.2Recommendation…………………………………………………………….54 Chapter Six...................................................................................................….....55 6. Summery and conclusion……………………………………………………………56

APPENDIX I…..………………………………………………………………………….57 REFERENCES…………………………………………………………………………...60

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List of Figures:

Figures 1: Mars Model of Individual Behavior Figures 2: Internal forces that affect a person’s behavior: Figures 3: Hierarchy Needs of Abraham Maslow's Figures 4: Two Factors Theory Figures 5: McClelland’s Acquired-Needs Figures 6: Process Theories Of Motivation Figures 7: Relationship Between Motivation And Performance Of Nurses

List of Tables:

Table 1: Table-1: Classification Of The Herzberg's Two Needs Factors Table 2: Table-2: Comparison of The Four Needs Theories

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CHAPTER ONE INTRODUCTION

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1. INTRODUCTION 1.1 BACKGROUND OF THE STUDY
"In order to become good in anything, the only talent you need is motivation"
Charles de Gaulle

Motivation is the key of a successful organization to maintain the continuity of the work in a powerful manner and help organizations to survive. Motivation is finding a need inside the employees and help to achieve it in a smooth process. Motivating the staff leads to broaden their skill to meet the organizational demands.Each manager should have the responsibility to work with the staff to find out their individual needs and put them side by side to the organization needs. Dissatisfaction also, might work as guidance for the manager to explore the need of the staff and start with it to motivate them and attract them to do better performance. Motivation drives the human beings to reach their goals and organization goals through every challenge and constraint they face in their workplace; considering it as an advantage to go ahead in the direction they have put for themselves. The need of achievement always results in a desire to do extra effort to have something done butter, and have the desire for success. The manager should motivate the employees to get things done through them without asking them what to do. Motivation creates a productive employee who saves time and effort. The motivated employee volunteers to do more than what is expected and more successful achievement than others. Such employee could be a good recourse and a model to be followed by other staff and adds positive input to the work within the organization. It is not just the matter of how motivated the staff are, but also how prepared they are for the job. Good performance depends on whether staff able to do things, or whether they are welling to do things. The level of performance depends on the level of motivation that stimulates someone to work and carry out the necessary tasks to achieve the goals. The managers have to learn to place the right person in the right place. A person should be given the role where they can use their skills and abilities and be concentrated towards the organization's goals and personal goals. Misplacements can cause dissatisfaction, less motivation, less concentration that leads to turnover and shortage of staff, commitment of mistakes, and loss to the organization. The motivation is important in any workplace and it is personal and different for each employee. Depends on different needs; different strategies will be created to satisfy these needs. Several need and motivation theories have been discussed in the study to clarify what might affect the motivation. So, without motivation nothing unique will ever happen that allows the organization to specialize with its production.

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In the project the nursing organization was chosen because it is a sensitive career that affects patient's life; if it dose not given the important consideration that is supposed to be.

1.2 RESEARCH PROBLEM
The aim of this research is to explain and describe how motivation of nurses in Aramco Health Center affects the performance and the delivery of care. It also discusses the problems of de-motivation and how adverse effects they have on the delivery of health services. That will ensure that, nurses have a work environment with the characteristics of work known to be linked to job satisfaction, motivation and good outcomes.

1.3 OBJECTIVE OF THE STUDY
In this project, the primary objective is to assess the quality of performance in nurses and motivation process used with them, categorized the different types of motivation theories, emphasize how importance of the relationship between motivation and the performance, and finally to create some solutions to motivate the nurses.

1.4 LIMITATION
The results of this study clearly showed that there were motivational effects on the performance of the nurses. There was limited time to have face to face meeting to explain any confusion with the questionnaires. There was some difficulty getting the nurses answer the survey questions because of their workload and the responsibility they have. Some nurses were unsure if it is legal with the company to answer such questions through their e-mail or to give true answers that might affect their job.

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CHAPTER TWO LITERATURE REVIEW

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2. LITERATURE REVIEW 2.1. INTRODUCTION
The success of any organization depends on the ability of managers to provide a motivating environment for its employees. The challenge for managers today is to keep the staff motivated and performing well in the workplace. The manager has to know the behavior of each employee and what might motivate each one individually. By understanding employees' needs, managers can understand what rewards to use to motivate them. The goal of most companies is to benefit from positive employee behavior in the workplace by promote a win–win situation for both the company and workers. The MARS model of Individual Behavior is an excellent medium for creating the win-win relationship between the employer and employees to understand motivation we have to know MARS Model of individual behavior.

2.1.1. MARS MODEL OF INDIVIDUAL BEHAVIOR:
MARS model is a model that explain individual behavior as a result of internal and external factors or influences acting together The name of the model is an acronym of the four major factors that have an affect on employee performance Motivation, Abilities, Role perception and Situational Factors. Individual values, personality, perceptions, attitudes, and stress form a basis on which the factors interact. ("MARS model of individual behavior" <http://en.wikipedia.org/wiki/MARS_model_of_individual_behavior>)

Values Personality Perceptions Attitudes

Motivation

Role perception

Individual behavior and results
Abilities Situational Factors

Stress

Figure- 1: MARS MODEL OF INDIVIDUAL BEHAVIOR

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These factors are highly interrelated in organizations. Unless all of the elements of the MARS model are satisfied, employee behavior and performance will be affected and negatively impacted. For example, enthusiastic and employee with high motivation level who is skilled in running the work (ability), and understands the job duties (roles perception) well, will not be able to perform their job well if there is a lack of the adequate and sufficient resources (situational factors). 2.1.1.1 Motivation The word motivation is derived from the word motivate which means to move, or to act to satisfy a need or want. Any consideration, idea or object prompting the individual to act or move to do what needs to be accomplished is what motivation is. Motivation may therefore be defined as a willingness to exert effort to achieve a goal or objective for rewards. Internal forces that affect a person’s voluntary choice of behavior: 1. Direction: is directed by goals 2. Intensity: is the amount of effort allocated 3. Persistence: is the amount of time that effort is exerted

Direction

Intensity

Persisten

Figure-2: Internal forces that affect a person’s behavior:

2.1.1.2 Employee ability Aptitudes, skills, or personal characteristics and the learned capabilities required to complete a task successfully Job matching is to put the right person in the right place 1. Select qualified people 2. Develop employee abilities through training 3. Redesign job to fit person's existing abilities 6

2.1.1.3 Role perception It is the behavior that required to achieve the desired results The employee has to: 1. understanding what tasks to perform 2. understanding relative importance of tasks 3. understanding preferred behaviors to accomplish tasks The employer has to: 1. Provide information about tasks and priorities 2. Provide frequent performance feedback 3. Provide training on preferred work processes

2.1.1.4 Situational factor Environmental conditions that constrain or facilitate behavior 1. Time 2. People 3. Budget 4. Work facilities

2.2 MOTIVATIONAL THEORIES
Several research studies on motivation have been undertaken by industrial psychologists and behavioral scientists. As a result, some theories about motivation and human behavior have been developed by researchers. Theories of motivation explore the sources of pleasure that people experience when they maintain equilibrium and preserve homeostasis by avoiding pain and over stimulation. The dynamic process of change in and of itself has important implications for employees in modern organizations. In particular, it affects their basic need to know who they are as a secure anchor amid incessant change. Frequent changes in organizations and in technology influence the power structure, the skills needed to excel on the job, an organization's values, and its managerial philosophy. Work motivation research began, as did the psychology of motivation in general, as a branch of individual psychology. However, more than theories of personality and human abilities, theories of work motivation traditionally have encompassed both individual and situational characteristics. 7

2.2.1 HIERARCHY NEEDS OF ABRAHAM MASLOW'S THEORY OF NEED
Abraham Maslow proposed the theory called hierarchy of needs theory. Maslow believed that within every individual, there exists a hierarchy of five needs and that each level of need must be satisfied before an individual pursues the next higher level of need. The five levels of needs, according to Maslow are: 1. Physiological Needs. These needs are essential to sustain life include food, water, air and sleep. According to Maslow's theory, if these needs are not met, then all other needs will not felt or be a source of motivation. 2. Safety Needs. This refers to the need to feel safe from physical and emotional harm. These needs include medical insurance, job security, financial reserves. 3. Social Needs. These needs are concerned with social interactions with others. The individual needs to feel a sense of belonging, affection, acceptance, and friendship. 4. Esteem Needs. Esteem is concerned with the feelings of self-confidence derived from achieving something and the sense of belonging. Esteem needs may be classified as internal or external. Internal esteems are these related to respect and achievement. External esteem needs are those such as social status and recognition that comes with the achievement. 5. Self-Actualization Needs. This level of needs is concerned with achieving ones full potential and dreams. Unlike lower level needs, this need is never fully satisfied; as one grows psychologically there are always new opportunities to continue to grow. This needs include truth, justice, and wisdom.

Self

actualization

Esteem

Love/ Belonging Safety Physiological
Figure-3: HIERARCHY NEEDS OF ABRAHAM MASLOW'S

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According to Maslow, only a small percentage of the population reaches the level of self-actualization. The organization can satisfy its employees’ various needs. In the long run, physiological needs may be satisfied by the person’s paycheck, but it is important to remember that pay may satisfy other needs such as safety and esteem as well. Providing generous benefits that include health insurance and companysponsored retirement plans, as well as offering a measure of job security, will help satisfy safety needs. Social needs may be satisfied by having a friendly environment and providing a workplace conducive to collaboration and communication with others. Company picnics and other social get-togethers may also be helpful if the majority of employees are motivated primarily by social needs. Providing promotion opportunities at work, recognizing a person’s accomplishments verbally or through more formal reward systems and job titles are ways of satisfying esteem needs. Finally, self-actualization need may be satisfied by the provision of development and growth opportunities on or off the job, as well as by work that is interesting and challenging. By making the effort to satisfy the different needs of each employee, organizations may ensure a highly motivated workforce. The important aspect of Maslow's model is that it provides for constant growth of the individual. The individual is always striving to do things to the best of one's ability, and best is always defined as being slightly better than before. There has been a great deal of debate over Maslow's hierarchical concept of motivation. It has a basic attraction to most people because it seems to be logical, to make sense. ("Business Management Articles", April 10, 2009, <http://www.envisionsoftware.com/articles/>)

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2.2.2 ERG Theory
ERG theory, developed by Clayton Alderfer, is a modification of Maslow’s hierarchy of needs. Instead of the five needs that are hierarchically organized; Alderfer proposed that basic human needs may be grouped under three categories, Existence, Relatedness, and Growth. The theory's name is based on the first letter of each need. Existence: Refers to our concern with basic material existence motivators. Physiological and safety needs (such as hunger, thirst and safe condition) Relatedness: Refers to the motivation we have for maintaining interpersonal relationships. Social and external esteem needs (such as involvement with family, friends, co-workers and employers). Growth: Refers to an intrinsic desire for personal development. Internal esteem and self actualization need (such as the desire to be creative, productive and to complete meaningful tasks). The implication of this theory is that we need to recognize the multiple needs that may be driving individuals at a given point to understand their behavior and properly motivate them. ("Business Management Articles", April 10, 2009,
<http://www.envisionsoftware.com/articles/>)

2.2.3 Two-Factor Theory of Fredrick Herzburg
The two-factor theory of motivation includes hygiene factors and motivators. The theory explains the factors that motivate individuals through identifying and satisfying their individual needs, desires and the aims pursued to satisfy these desires. Herzberg labeled factors causing dissatisfaction of workers as “hygiene” factors, and factors that causing satisfaction of workers as “motivator” factors 2.2.3.1Hygiene factors This included company policies, supervision, working conditions, salary, and safety and security on the job. Examples would be when people felt they weren’t paid enough, didn’t like their supervisors, were not happy about their working conditions or were insecure in their jobs. However, if they felt that the maintenance factors were satisfactory, that is, their pay and other working conditions were good; they only maintained current levels of production and efficiency.

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2.2.3.2 Motivator factors They are factors that are intrinsic to the job, such as achievement, recognition, interesting work, increased responsibilities, advancement, and growth opportunities. 1. 2. Achievement – Personal accomplishment or the feeling of having done a job well. Recognition – Being recognized for the efforts and accomplishments of the work by receiving a company reward, promotion, or salary increase. Participation – being involved in some responsibility of the work like making decisions and suggestions for the organization..

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4. Growth – challenge of the job itself; and the chance to learn skills, acquire knowledge, and achieve development and advancement. As more varied tasks are included in the job under the job enrichment program, the work is made more interesting and challenging, the job becomes more satisfying and the employees more productive. According to Herzberg’s research, motivators are the conditions that truly encourage employees to try harder. Focusing on hygiene factors will not be enough, and managers should also enrich jobs by giving employees opportunities for challenging work, greater responsibilities, advancement opportunities, and a job where their subordinates can feel successful. In applying Herzberg’s Two-Factor Theory to create a high level of performance, certain measures must be adopted by management such as job enrichment or restructuring the job to make it more interesting and challenging to the worker. This application of job enrichment is popular because it can easily be adopted by all levels of management, payoffs can be realized in a relatively short time span, and it cam be measured in specific terms. These two separate needs are the need to avoid unpleasantness and discomfort and, at the other end of the motivational scale, the need for personal development. A shortage of the factors that positively encourage employees (the motivating factors) will cause employees to focus on non-job related ones. ("Business Management", articles, April10, 2009, http://www.envisionsoftware.com/articles/)

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Dissatisfaction and de-motivation

Not dissatisfied but not motivated
Figure-4: Two Factors Theory

Positive satisfaction and motivation

Herzberg classified the two needs factors as follows:

Hygiene or Maintenance Factors (Job Environment) Extrinsic Factors Company policy and administration Supervision Interpersonal relations Working conditions

Motivation Factors (Job Content) Intrinsic Factors Work itself Achievement Responsibility Growth and advancement

Table-1: classification of the Herzberg's two needs factors

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2.2.4 Acquired-Needs Theory of David McClelland’s
Acquired Needs Theory is also known as the Three-Need Theory or Learned Need Theory. According to acquired-needs theory individuals acquire three types of needs as a result of their life experiences.

Some needs could be learned; these needs are:

2.2.4.1

Need for Achievement (nAch)

Achievers seek to appreciate frequent recognition of how well they are doing. They prefer working alone rather than in teams They will avoid low risk activities that have no chance of gain. Money is a weak motivator among these achievement, except when it provides feedback and recognition They will avoid high risks where there is a significant chance of failure. They set moderate, realistic, achievable goal.

2.2.4.2

Need for Affiliation (nAff)

Affiliation seekers look for harmonious relationships with other people. They tend to conform and shy away from standing out. They seek approval rather than recognition. They try to project a favorable image of themselves and take other steps to be liked by others. They support others and try to smooth out conflicts that occur in social sitting. They try to project a favorable self-image. They prefer working with others rather than alone. They enjoy lots of social activities. They seek to belong, join groups and organization.

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2.2.4.3

Need for Power (nPow)

Power seekers want power either to control other people or to achieve higher goals. They seek to make more suggestions in meetings. They seek to help others, such as improving society or increasing organizational effectiveness. They seek neither recognition nor approval from others; only agreement and compliance. They enjoy competition and winning, and do not like to lose. They are willing to confront others.

All individuals possess a combination of these needs, and the dominant needs are thought to drive employee behavior. Heller, J., Goulet, L., Mohr, E., (2004)

Need for achievement (nAch)

Need for affiliation (nAff)

Need for Power (nPow)

Figure-5: McClelland’s Acquired-Needs

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2.3 COMPARISON OF THE FOUR NEEDS THEORIES
MASLOW NEED HIERARCHY THEORY Self – actualization Esteem Social safety Physiological ALDERFER ERG THEORY Growth Relatedness Existence MCCLLAND MANIFEST NEED THEORY Power Achievement affiliation

HERZBERG TOWFACTOR THEORY motivators Hygiene

Table-2: COMPARISON OF THE FOUR NEEDS THEORIES

2.4 PROCESS THEORIES OF MOTIVATION
It describes how employees are motivated or how they select behaviors to meet their needs and determine whether they made the most successful choice. Process explanations of motivation suggest that motivation varies from situation to situation.

Satisfaction or dissatisfaction

Need

Rewards

The Employee

Motivation

Performance

Behavior

Figure-6: PROCESS THEORIES OF MOTIVATION

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2.5 PERFORMANCE
Herzberg says "Having fewer dis-satisfiers does not motivate a worker to do a good job, but only to stay in it". Worker performance clearly depends on their level of motivation, which stimulates them to come to work regularly, work diligently, be flexible and be willing to carry out the necessary tasks. The performance and quality of a health system depend on the quality and motivation of health human resources. Therefore, nurses' motivation is likely to have effects on the delivery of health services and the outcome of care and performance of work. There, low motivation and poor job satisfaction have a negative impact on the health sector, harmfully affecting job performance as well as the quality of care. The productivity of nurses is not just a matter of how motivated they are for the job, it is also a matter of how well trained and prepared they are for the job. To better understand the factors influencing the motivation and performance of nursing, we have to develop and test relevant methods of assessment, which will better help to design context-specific strategies for improvement. Aramco Health Center is using SAP System that evaluates the achievement and the performance.

2.6 HOW DOSE MOTIVATION AFFECT PERFORMANCE
Motivation is the internal process that leads to behavior that satisfies needs. 2.6.1 Performance formula Performance = Ability ×Motivation ×Resources (2x2x2=8) Without motivation performance is usually below potential. (2x0x2=0) ("Carter, S., Shelton, M., The Performance Equation - What makes truly great, sustainable performance", Apter Development LLP (2009) <http://www.apterinternational.com/articles/PerformanceEquationArticle060 9.pdf>)

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2.7 WHY TO MOTIVATE NURSES?
Nursing is a sensitive career that plays an important role in society. It is a multi skill career that should be rewarded because nurses are the eye of health care staff about patients' condition. Nurses are placed in a work which forces them to deal with pain, sickness, death and depression. They deal with human beings, no mistakes are allowed; it could be a patient life or the patient might be at risk for suffering. The nature of their work is tough and stressful, because of the long working hours, shift working hours, and they have to work during holidays and other occasion time, so they loose their normal life style. At the same time, the expression of feeling in front of the patients is not acceptable. The nurse should have the skills and abilities to deal with situations like doing care after death and be sympathy with the family of a patient who died, and continue her work with another patient having a smile on her face. It is the ability and the art of handling stress in a positive attitude. At the end, nurses are human beings who need to be rewarded for their great job in reducing suffering of patients and saving lives at least with a thankful word to absorb their stresses during their work and allow them to be motivated to perform high standard of care, work harder, and move along with their tough career. Unmotivated staff has a bad effect on the delivery of care of patients and the quality of care. If a nurse cannot find anything motivates him/her to do the work, leaving the workplace could be the butter idea; instead of doing medical mistakes that could affect their dignity. This may occur as a result of lack of interest to work or work under stress and being less concentrated and less productive. That can explain the presence of shortage within nursing allover the world. So, hospitals need to know how to motivate their nurses and show them that their effort was of value to keep them from burning off. Motivation works as supportive tool that enhances nurses to success and go along with their work. Motivating the nurses is not the only issue, but motivating them in a way having their sense of responsibility toward their work to ensure the safety of the patients.

2.8 CAUSES OF DEMOTIVATION
The role of nursing is associated with multiple health care professionals and forced by nurse supervisors and managers, and by medical and administrative staff which increase work overload and conflicting demands and stresses. Role conflict of this kind may be most obvious when dealing with patients who are critically ill and dying. stress generally detracts from the quality of nurses’ working lives, increases minor psychiatric morbidity, and may contribute to some forms of physical illness, with particular reference to musculoskeletal problems, stress and depression.

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Shortages, overwork and unequal pay can lead to resentment and low morale at hospitals. This in turn undermines the quality of medical care patients receive.

2.8.1 WORKPLACE VIOLENCE
"violence is threats, or a threatening statements or threatening behaviors that give a reasonable cause to believe that the employee is at risk of physical injury, as well as attempted conduct of a person that endangers the physical health or physical safety of the employee" Occupational Health and Safety Act (1996). Violence can occur in many forms. The nurses are at an increased risk for being victims of violence. These include physician to nurse, nurse to nurse, client to nurse and family to nurse violence. This violence can be manifested through physical, sexual, verbal, emotional and psychological actions, violence can occur in other forms such as excessive workloads, unsafe working conditions, and inadequate support. Some findings suggest a direct link between aggression and increases in sick leave, burnout and staff turnover. The costs of improving nursing protection in the workplace should be balanced against the costs associated with the lost hours and turnover resulting from violence against nurses.

2.8.2 WORKPLACE HAZARDS AND INJURIES
There are many risks in healthcare that have the potential to cause serious injury. One of the most common risks healthcare professionals, including nurses, may encounter are sharps injuries. Some of these injuries can expose nurses to blood borne infections that are potentially life threatening, such as Human Immunodeficiency Virus (HIV) Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV).

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2.8.3 LONG WORKING HOURS
Work patterns of long working hours can also affect nurses' social life. As nurses often has less time to be spent with loved ones. This can lead to impaired relationships. Lack of quality interaction with friends and family also increases the risk of isolation and loneliness. Shift workers may also experience difficulty in accessing adequate childcare services and care. Long working hours has effect on family and social life of the nurses.

2.8.4 EFFECT OF NIGHT SHIFT
Being that shift workers are required to function against their body’s natural rhythm. On average, shift workers get two to four hours less than the recommended eight hours of sleep in twenty-four hours. The human body normally follows a 24-hour cycle called the circadian rhythm. This cycle regulates sleeping, waking, digestion, secretion of adrenalin, body temperature, pulse and many other important aspects of body functions. If a person alters his or her activity patterns, these rhythms can go out of sync, leading to disorientation and feelings of fatigue. Nurses need to increase awareness of shift work’s effect on performance and patient safety. (Abdalkader, R., Hayajneh,F., (2008), Effect of Night Shift on Nurses Working in Intensive Care Units at Jordan University Hospital <http://www.eurojournals.com/ejsr_23_1_07.pdf>)

2.8.5 SHORTAGE AND TURNOVER PROBLEM
Nursing used to be about caring for sick patients, fixing what was wrong so that they could return to their lives. The challenge of nursing now relates more to wellness approach, accessing information, guiding, teaching, counseling, linking, and collaborating with clients to change their lifestyles.

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The nursing is a distinct scientific field and autonomous profession whose skilled practitioners save lives and improve patient outcomes every day in a wide variety of settings. Staff shortage is inadequate quantity of skilled nurses in clinical settings that has a significant negative impact on patient outcomes, including mortality. The nursing shortage is literally taking lives, and impairing the health and wellbeing of many millions of the world's people. It is a global public health crisis that has been reported in most countries of the world. The causes of short staffing include poor work conditions, inadequate resources for nursing research and education, nursing is mostly female nature, training of new staff and increased overtime and use of temporary agency staff to fill gaps, and the increasing complexity of health care and care technology. Turnover expresses the percentage of nurses that are lost each year through retirement, death, international migration or moving to work in another sector of the economy, or due to employees leaving for their own reasons like; career progression, overtime and use of temporary agency staff to fill gaps, better pay in a new job, or dissatisfaction in the current job. Shortage and turnover may lower quality and productivity of nursing care, due to the loss of work group efficiency and organizational performance. Various indicators can be used to assess the degree of shortages, related to both such as absenteeism, retention rates, vacancy rates and turnover.

2.8.6 FEELING UNDER PAID
"The nurse does for the patient (only) what they would do for themselves if they were healthy" Virginia Henderson, the famous nursing theorist. It is struck how multi-skilled nurses have to be, and how little this was reflected in their pay. The salary is one of the motivators. Most nurses feel underpaid and undervalued. Nurses have to learn the role of a clerk, counselor, teacher, auxiliary, doctor, psychologist, housemaid and mortician. They have to administer medicines, advise patients and care givers, perform observations, write handover reports,

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change beds, work hoists, bath patients, scrub dentures and wash dead bodies. Nursing must be one of the world’s most multi-sided occupations. Comparing with other health professionals and the level of responsibility nurses having, they are paid an unfair wage that is not reflecting their workload and level of responsibility. There is a huge difference between nurses’ salaries and those of more narrowly specialized personnel like doctors, radiology, and lab technicians. Nurses may acquire ever more skills but it does nothing to improve their status or their income. From unfair salary rankings to understaffing, nurses frustrated and distressed by a system which does not support their concerns and needs. The report of the survey that was done on some of Aramcos' nurses is showing that nurses have received lower payment on a lower grade code than other health professional 86% indicated that, they are receiving unfair salary comparing with other health staff. Nursing pay calculations would provide a basis for quantifying and rewarding a nurse’s range. It might also motivate them to broaden their skill base constantly to meet changing healthcare demands.

2.8.7 LACK OF APPRECIATION
Many people think that a nursing degree is not as respected as a medical school. It is important to realize that nurses are needed in growing numbers throughout the world. Nurses take care of patients and do a fairly large amount of the physical work involved. As nurses progress through their education, they are placed into clinical settings to obtain real hands on experience. Nurses are not stuck behind a desk for 8 hours a day staring at a computer. They get to interact with many different people on a daily basis. They can specialize in areas such as renal therapy, emergency room nursing, or surgical nursing. The specialties available are endless.

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Appreciation is an acquisition of a positive feedback. It is the innate feeling that the work of employees is valued and makes a difference to their performance. Nurses need to feel that, their profession should be seen as important to the workings of the whole team and the effort they do is appreciated. Lack of appreciation has a negative effect on stress and job satisfaction and could adversely influence staff turnover. Respect from supervisor and other staff by acknowledging their contribution, recognition of their skills, and respection for their work is consider a way of appreciation. Being part of a team and the sense of belonging is another way makes the employee feel more valued. Nursing appreciation could be a simple thank you from a patient, a respect from a co-worker, or recognition from a supervisor. (Johnson, J. A. (2009) Health Organizations, Theory, Behavior, and Development) & (Clavreul G., M., (2004), Demotivation in the Nursesing profission the Causes, Working Nurse).

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2.9 FACTORS AFFECTING NURSING MOTIVATION AND PERFORMANCE
Motivation at work is widely believed to be a key factor for performance of individuals and organizations and is also a significant of intention to turnover. There is a strong link between job dissatisfaction, lack of motivation and intention to turnover. The hospital managers has to keep the right nurses in the right place, which requires identifying and understanding the factors affecting nurses' motivation and performance. Incentives and rewards are important because they can influence performance. There are three factors play a key role in nursing performance: The ability of staff to do their job;(The capacity or "can do" factors) The motivation of staff to put in effort to do the job (The ability or "will do" factors) The organizational support or opportunity to do the job well (availability of resources) In other words, performance depends on whether the staff perceive themselves as able to do things, whether they are willing to do things and whether they have the means to do them.

2.10 RELATIONSHIP BETWEEN MOTIVATION AND PERFORMANCE OF NURSES
Individual factors Capacity or "Can do" Motivation factors Ability or "Will do" Organizational factors "Resources"
Figure-7: Relationship between Motivation And Performance Of Nurses

Employee's need

Performance

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2.11 HOW EMPLOYEE MOTIVATION AFFECTS EMPLOYEE PERFORMANCE
The extent to which employees are motivated in their work depends on how well those employees are able to produce in their job. Motivation is expected to have a positive effect on quality performance; employees who are characterized by a high level of motivation show a higher work and life satisfaction. Having a high level of motivation is therefore in itself valuable for employees and a decrease in motivation might affect employees negatively. The motivation leads to high level of initiative and creativity from the employees and where monitoring is difficult, motivation is therefore extremely important for ensuring high quality performance. In Armco Health Center the quality of employee performance is measured by three individual measures of employee performance. The first measure of the individual performance items is a self-rating measure of employee performance through a program called SAP. The performance of the employee asks to indicate eight-points scale how well the employee is doing the job. The second measure of the performance of the Armco Health Center is the extent to which the nurses are willing to conduct tasks that are not part of their job description. The employees are asked to report on the SAP about their willingness to perform additional tasks that are not expected from them regularly, and to think constructively about how the organization they work for could be improved. Last items that measure the performance of the nurses are the number of days they were absent.

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2.12 TYPES OF REWARDS
"You get more of the behavior you reward. You don't get what you hope for, wish for or beg for. You get what you reward." Michael le Boeuf Reward system is much more than just bonus plans and stock options. It is a process that reinforces behavior to hit the target and meet the standards. Rewarding performance should be an ongoing managerial activity, not just an annual ritual.

2.12.1 Monetary rewards Monetary rewards are certainly the most common approaches used to improve recruitment, retention, motivation and performance. Financial rewards include direct or indirect payment such as wages or salary, bonuses, insurance, merit pay, allowances, loans and tuition reimbursement. Providing adequate and timely reward is important to guarantee the recruitment of motivated and qualified staff.

2.12.2 Non-monetary rewards There are different types of non- monetary rewards, such as work autonomy, recognition from supervisors, so employee will feel their efforts are noticed and valued. Career development and Professional growth opportunities will help employees to develop new skills, expand their knowledge, and increase their visibility within the organization, internal promotion opportunities as a long plan, and shift work flexibility.

(Kotelnikov, v., "Effective Reward Systems Increasing Performance and Creating Happier Employees" <http://1000ventures.com/business_guide/crosscuttings/motivating_reward _system.html>)

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CHAPTER THREE RESEARCH METHODOLOGY

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3. RESEARCH METHODOLOGY

3.1 RESEARCH DESIGN
The current research is conducted to determine nurses' motivation and its effect on their work and production. The research design is quantitative data. The results obtained will help the management to explore the factors affecting motivation and make appropriate changes to motivate the nurses.

3.2 RESEARCH ANALYSIS
The model was tested with nurses working in Aramco Health Center. The data were collected through questionnaire that was done on 30 nurses who work at Aramco health center and were distributed to them through their e mail. The questionnaire method was used to generate high number of data and at the same time it minimizes the time and effort required of the respondents, rather than interviewing each nurse individually.

3.3 DATA COLLECTION
Out of total 30 questionnaires distributed, only 20 questionnaires were received back. The questionnaires focused on the causes that might affect the motivation and the level of satisfaction of the nurses.

3.4 DATA SAMPLING
The target audient for this research includes Saudi Arab, Westerns, and Asians nurses work in Saudi Aramco Health Center. The questionnaires were distributed through their e mail.

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3.3 DATA COLLECTION
The model was tested with nurses working in Aramco Health Center. The data were collected through questionnaire that was done on 30 nurses who work at Aramco health center and were distributed to them through their e mail. Out of total 30 questionnaires distributed, only 20 questionnaires were received back. The questionnaires focused on the causes that might affect the motivation and the level of satisfaction of the nurses.

1. Gender:
Male Female 5 18
Table No. 1

2. Age:
Less than 30 More than 30 11 12
Table No. 2

3. Are you motivated to perform well in your work?
Yes No 11 12
Table No. 3

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4. If no, what are the reasons? (Check all apply)
workplace violence workplace hazard and injuries long working hours effect of night shift shortage problem feeling under paid unreasonable workload lack of appreciation 2 0 7 3 4 5 6 12
Table No. 4

5. Estimate how well you understood what was required of you
Not Poor Fair Well High
Table No. 5

0 1 5 13 4

6. The certificate to be a nurse is attractive for working as a nurse
Yes No 14 9
Table No. 6

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7. How satisfied are you with your job?
Not Poor Fair Well High
Table No. 7

2 0 12 8 1

8. Your boss recognizes my efforts
Not Poor Fair Well High
Table No. 8

2 1 13 4 3

9. Do you think that the payment you get is fair comparing with other health workers?
Yes No 2 21
Table No. 9

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10. What might motivate you more?
Monetary reward Non monetary reward 13 10
Table No. 10

11. Dose shift work affects your mood?
Yes No 13 1
Table No. 11

12. Nightshift increase interpersonal conflict in your family
Yes No 10 4
Table No. 12

13. Nightshift increase interpersonal conflict in your work
Yes No 8 6
Table No. 13

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14. How would you rate your productivity?
Not Poor Fair Well High
Table No. 14

0 1 0 10 11

15. What has happened to your productivity in the last six months?
Stayed the same Gone up Gone down 8 13 1
Table No. 15

16. Do some nurses in your company drop out from the hospital?
Yes No 16 7
Table No. 16

17. Do you feel stressed out most of the time?
Yes No 13 10
Table No. 17

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18. Do you miss some of your family's important events because of the shift work hours?
Yes No 13 1
Table No. 18

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CHAPTER FOUR DATA ANALYSIS AND RESULTS

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4. ANALYSIS AND RESULTS
The data collected through questionnaire that was done on nurses who work at Aramco health center. Out of 30 questionnaires distributed only 23 were answered. The data obtained are analyzed as followed:

1. GENDER:

Figure No. 1

The inquiry was made to find information about the gender of the nurses. As nursing is a female job in nature; the result showed highest number of female 78% were female nurses while the male were only 22%. Woman has major role to playing the life and they compromise their sleep to take care of their children and family tasks.

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2. AGE:

Figure No. 2

The inquiry was made to find information about the rate of the age of the nurses. The data result showed almost equal percentage of age groups, above or less than 30 years old were responded to the questionnaires. 52% of the nurses were more than 30 years old and 48% were under 30.

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3. MOTIVATION TO WORK

Figure No. 3

The inquiry was made to find how motivated the nurses with their work are. The result showed that 48% of the nurses are motivated and around 52% of them are not motivated to work. Unfortunately about half of the number of nurses are not motivated which is a large percentage. This indicates that, there is a serious problem with motivation among nursing.

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4. FACTORS OF DE-MOTIVATION

Figure No. 4

The research inquired to find out factors that might affect nurses' motivation and performance. The highest number agreed that lack of appreciation is affecting their performance more. 31% agreed that lack of appreciation is the reason of being de-motivated. 15% seen that, unreasonable workload as a factor of de-motivation. 13% feeling that their payment is unfair comparing with other health staff. 10% are suffering from shortage problem. 10% got a problem with night shift; while18% of the nurses found long working hours is a problem for them. 5% only agreed that workplace violence is a factor of de- motivation. None of the nurses are suffering from workplace hazard or injuries it could be because of the high technique used in the hospital to prevent such problems.

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5. UNDERSTANDING THE REQUIREMENTS

Figure No. 5

The inquired was made to find out withier the employees understand their requirements or not. The highest number knows well what their requirements are it is about 57% of the nurses, 22% has a fair knowledge, 17% with highly understand the requirement only 4% with poor understanding. Understanding what the requirements are will help the employees to perform their work well.

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6. Attractiveness to work before practicing nursing in reality

Figure No. 6 This inquiry showed the rate of motivation to work before practicing the work with its de-motivation factors and stresses. 61% were motivated by their certificate, while 39% were not. The result showed the difference in being motivated to work but later on this percentage has been changed from 61% to 52% as shown in Figure No. 3.

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7. JOB SATISFACTION

Figure No. 7 This inquiry showed how satisfaction the nurses are with their work. The highest rate was given as fair satisfaction which is not the rate needed to satisfy the employees to work and be creative at their work. 52% of the nurses rate their satisfaction as fair satisfaction. 35% are well satisfied with their work. 9% are not satisfied with their job. 4% are satisfied but this is a very low rate to perform a good job.

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8. RECOGNITION OF THE EFFORTS BY THE BOSS

Figure No. 8

This inquiry showed the recognition of the efforts by the boss. The busses need to recognize the work and the effort of the employees because they have an effect on the performance and the motivation of the workers. 57% feel that their boss is fair in recognizing their efforts. 17% agreed it is well recognized. 13% are highly recognized, but it is a very small number. 9% of them are not recognized which is unfair for an employee to do effort with no appreciation. 4% feel that their boss is poor in recognizing their effort.

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9. FAIRNESS OF PAYMENT

Figure No. 9

The inquired was made to find out the fairness of the payment of nurses comparing to other health workers. 91% feel that their payment is unfair which a very huge number. Only 9% are satisfied with their salary.

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10. REWARD SYSTEM

Figure No. 10

The inquiry was made to find information about the reward system followed in Aramco Health Center. Monetary reward considered one of the important rewards to the nurses as seen in the figure. 57% agreed that monetary reward is important to them. 43% seen non- monetary rewards are much important to them like education, promotion or growth opportunities.

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11. THE EFFECT OF NIGHTSHIFT ON THE MOOD

Figure No. 11

In this inquiry, out of 23 nurses, only 14 of the results were taken into consideration because 9 of them do not work nightshift but regular working hours. The research inquired to find the effect of night shift on the nurses' mood. The nightshift affects the mood of 93% of the nurses that might affect their work. Only 7% do not feel changes in their mood because of the shift work.

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12. THE EFFECT OF NIGHTSHIFT ON THE FAMILY

Figure No. 12

In this inquiry, out of 23 nurses, only 14 of the results were taken into consideration because 9 of them do not work nightshift but regular working hours. The research inquired to find the effect of night shift on the family. The result showed 71% of the nurses are affected by nightshift. 29% has no problem with their family because of the shift wok.

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13. THE EFFECT OF NIGHTSHIFT ON THE WORK

Figure No. 13

In this inquiry, out of 23 nurses, only 14 of the results were taken into consideration because 9 of them do not work nightshift but regular working hours. The research inquired to find the effect of night shift on the nurses' work. A rate of 57% of nurses’ work is affected by nightshift. 43% has no affect on their work by the nightshift. Nurses’ work means patients’ life; so, it is very important to put this into consideration.

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14. PRODUCTIVITY RATE

Figure No. 14

The research inquired to find the productivity rate of the nurses. The result showed 50% are highly productive. 45% are well productive and 5% are poor in their productivity.

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15. THE PRODUCTIVITY RATE

Figure No. 15

The research inquired to find the rate of the productivity again, but this time in specific period of time. 59% of the result showed the rate of productivity gone up. 36% has no motivation to raise their productivity, so it is at the same rate. 5% of the result showed the rate of productivity gone down.

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16. DROPPING OUT RATE

Figure No. 16 The inquiry was made to find information about dropping out and turnover problem with nurses, since it is a serious universal problem. According to the result 70% of the nurses agreed that there is a dropping out problem in Aramco Health Center. 30% only do not feel dropping out as a problem in the Center.

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17. RATE OF STRESS

Figure No. 17

The inquiry was made to find out how stressed the nurses are. The result indicated that 57% has stress in their work. While 43% have no stress. The percentage of the stress rate is not an easy number. If the nurses have such rate it could affect on the patient care and the organization itself.

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18. THE EFFECT OF SHIFTWORK ON SOCIAL EVENTS

Figure No. 18

The inquired was made to find out if the work shift has effect on the family or the social events. 93% of the results are affected by nightshift. Only 7% has no effect. Nightshift causes imbalance an between lifestyle and work.

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CHAPTER FIVE DISCUSSION AND RECOMMENDATION

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5. DISCUSSION AND RECOMMENDATIONS 5.1. DISCUSSION
Nursing is a sensitive career that plays an important role in society. Nurses are the eye of health care staff about patients' condition. They deal with human beings, no mistakes are allowed; it could be a patient life or the patient might be at risk for suffering. The hospital managers have to understand the factors affecting nurses' motivation and performance. Unmotivated staff has a bad effect on the delivery of care of patients and the quality of care. If a nurse cannot find anything motivates him/her to do the work, leaving the workplace could be the butter idea; instead of doing medical mistakes that could affect their dignity.

5.2. RECOMMENDATIONS
The finding of this project suggested that, it might be interesting to explore the impact of supervisory behavior on the employees. Since supervisors evaluating the work performance; further study is needed to explore the influence of supervisors' expectancies on the nurses work evaluation. The supervisor may identify goals to the employees in the beginning of the year and then to evaluate the employees according to these goals Identify opportunities to provide constructive feedback to colleagues. The opportunity of higher education or getting a new position will highly affect the motivation of the employee. Provide supportive environment for nurses who work nightshift and to formulate strategies to assist the nurses who have difficulty to work nightshift. Facilitate good team working, support, respect for the roles and contributions of others to provide a motivating work environment is another way to increase the production of the workers.

Consultation involves others in decisions which have a direct influence on their work role, especially when their opinion has the potential to make a difference. There should be an employee plays a role of the guidance and be a reference to the other employees working in the same organization. The increase in attractiveness of the career system is expected to increase the quality of performance, because it is expected to increase the motivation.

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CHAPTER SIX SUMMERY AND CONCLUSION

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6. SUMMERY AND CONCLUSION
Motivation is the internal process leading to behavior to satisfy needs. Motivated employees help organizations survive as motivated employees are more productive. To be effective, managements need to understand what motivates employees within the work they perform, and to recognize motivation and performance; to find out motivation effects on employee performance. They need also to recognize basic need theories that help with these issues. In this research, we had focused on the effects of the motivation of nurses in Aramco Health Center on the employee performance. In doing so; we had focused on the quality of employee performance. Hospitals and other institutions need to know how to motivate their nurses to keep them from burning out or being de- motivated. De-motivated nurse can be very hazardous to patients.

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Appendix I
Questionnaires
Gender 1. Male 2. Female Age: 1. Less than 30 2. More than 30 Are you motivated to perform well in your work. 1. yes 2. no If no, what are the reasons? (Check all apply) 1. workplace violence 2. workplace hazard and injuries 3. long working hours 4. effect of night shift 5. shortage problem 6. feeling under paid 7. unreasonable workload 8. lack of appreciation Estimate how well you understood what was required of you 1. 2. 3. 4. 5. Not Poor Fair Well High

The certificate to be a nurse is attractive for working as a nurse 1. Yes 2. No

How satisfied are you with your job? 1. Not 2. Poor 3. Fair 4. Well 5. High 57

My boss recognizes my efforts 1. Not 2. Poor 3. Fair 4. Well 5. High Do you think that the payment you get is fair comparing with other health workers? 1. Yes 2. No What might motivate you more? 1. Monetary reward 2. Non monetary reward Dose shift work affects your mood? 1. Yes 2. No Nightshift increase interpersonal conflict in your family 1. Yes 2. No Nightshift increase interpersonal conflict in your work 1. Yes 2. No How would you rate your productivity? 1. Not 2. Poor 3. Fair 4. Well 5. High In the last six months, what has happened to your productivity? 1. Stayed the same 2. Gone up 3. Gone down

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Do some nurses in your company drop out from the hospital? 1. Yes 2. No If so, what are the factors? …………………………

Do you feel stressed out most of the time? 1. Yes 2. No

Do you miss some of your family's important events because of the shift work hours? 1. Yes 2. No

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