Knowing How to Make People Happy: Reflections on Health Worker Motivation
01/26/2011
IntraHealth's Barbara Stilwell reports from the Second Global Forum on Human Resources for Health in Bangkok
Today in Bangkok I participated in a session at the Second Global Forum on Human Resources for Health focusing on ways to find out what makes health workers happy. With a professional history in psychology, this is an enduring subject of interest for me.
Last year, I worked with the Ministry of Health in Botswana to develop a policy that encourages health workers to enter and stay in the public sector. As a part of this work, we surveyed, interviewed and spoke to more than 800 health workers. I did some of the interviews myself, in a remote area of Botswana, speaking to nurses, physicians and managers. It was an experience that is hard to forget, with the accounts of everyday life that could be so challenging and patients with such dire needs.
What we found out was not at all surprising. The health workers we spoke to want what so many of us want: strong management, which was variously expressed as having a ‘good work climate,' frequent supportive supervision, and adequate equipment to do a good job. They wanted their managers to take time to listen to them and to be patient when it comes to simple things, such as a request for leave. But these workers also reported that they would be more satisfied at work if their job allowed them to live with their children (95.1%) and with their partner/spouse (89.8%). For many health workers, being posted in a remote area means leaving their family, as there are no family accommodations available.
Well, who would not want these things, I wondered? These wishes are not, I am sure, unique to health workers, nor to any workers. This reminds us that job satisfaction is about more than the job, and it reminds us that human resources are not only important resources in the health sector, but they are also human. One of the most intriguing aspects about being human is our ability to feel happy - or not. When it comes to working, it is difficult sometimes for employers to know if we are happy or motivated. We may not say how we feel. More often we ‘act out' our happiness by working hard - or not, by doing a good job - or not, and by either staying at our job or leaving. What will make workers happy is the subject of much behavioral research, including our work in Botswana, and the focus of a workshop here in Bangkok.
The Discreet Choice Experiment
The Discreet Choice Experiment (DCE) is a method for determining preferences among a target study population and then weighing how important each of those preferences really are by forcing a person to make a ‘trade-off.' The DCE is often used in marketing: for example, this method could determine whether a prospective car buyer would prefer to pay full price and wait for a black car to arrive at the showroom or pay less and have a red car right away - thus giving some idea of the importance of color versus price.
In the case of health workers, DCE might ask, "Would you prefer to go to clinic A, in an urban area where you have no pay increase nor housing allowance, but the workload is heavy, and you will have to stay for 5 years? Or would you prefer clinic B, in a rural area, where the workload is light, you have a 30% pay raise, and have the option of living in a one-room house with shared bathroom and kitchen facilities, and have to stay for 2 years? Using this method and a series of questions, experienced researchers will be able to mathematically calculate which factor - pay, housing, accommodation, and so on - is most likely to encourage health workers to work in rural clinics.
Yet, this tool is by no means the answer to uncovering the secrets of worker motivation. It is just one tool that can be used to give a more complete understanding to a very complex subject: what makes us happy. As we all know, making hypothetical choices is not the same as real choices with full information. When I listened to the presentation, I tried to imagine how a person could reasonably decide if they were willing to live and work in a rural area if they had never been there. Though the response to the DCE might indicate that they would move there, once there, the reality might be overwhelming and they then leave.
So what does that mean for the health workforce?
It seems clear to me that we have to learn to live with and plan for this uncertainty, which means being flexible and willing to change strategies when our approach proves ineffective. To do this, we need really good indicators to know if a strategy is effective. And we should not be seduced by the prospect of certainty when it comes to human happiness, which, I think, may not be amenable to mathematical calculation.
Barbara Stilwell is the director of technical leadership at IntraHealth International.
Barbara, I really appreciate your comments about happy, motivated health workers. It is so true that we need to consider retention of health workers in a holistic manner, and not just salary, benefits and length of stay in a remote location. Health workers are motivated by not only providing high quality care but in their ability to take care of their families. I think that the situation in Botswana is a very important example of this. Botswana developed a policy years ago, which on the surface, seemed like a good idea—that is to equitably distribute health workers and teachers across the country. However, they did not consider their marital status and what that policy would do to their families. One of the unintended consequences of this policy was that the family spent very limited time together and contributed to the high rate of HIV/AIDS because of the separation (Ntseane, 1997). So the question is how do we as policy makers and HRH experts identify the gaps and strategies to improve satisfaction and retention of health workers in hard to reach areas and consistently evaluate the situation to see if that gap has improved or if unintended consequences have emerged. How do we develop a nimble policy environment to make adjustments? How do we build upon what was previously learned and implemented and not start over when a new project or administration begins? How do we keep our eyes on the holistic person when we are pressed to report on the numbers?
— Pamela McQuide on 2011-01-28
Thank you for your article. Many people oversee the simple things that do make a difference. Yes, being happy is important. Without going into defining what a happy health worker is, I believe happiness means remaining resourceful in spite of all the challenge health workers face every day. Nobody can solve many of the problems health workers encounter for them. Human resource management is not about improving the quality of care, but about improving the motivation of health workers to want to improve how they deliver care. The good news is that as you said motivation can be increased. You are right about being able to have and make choices. There is nothing more frustrating than feeling trapped in job without choices. Then, the only choice is to quit or leave the country. Sometimes the choices and opportunities are there, but health workers do not see them. It takes someone else, a friend, a colleague, a supervisor, or a coach to show them they have a choice - there are many things they can do. I remember a rural clinic I visited when I was working in the Philippines. The nurse was so frustrated. She spent half of her day filling up records she knew no one read and the other half waiting for patients for whom she could hardly do anything due to lack of medicines and supplies. Then, I noticed there was brand new baby scale still in its box on a table behind her. I asked if she ever used it. She said no. A donor had donated it but she had not had time to open the box yet. I asked if she could do anything with it. She said she could weigh the newborn babies if they came. I asked her what can be done to have the mothers come. She said she could have the local barangay captain (local authority) spread the word that there was a new scale and that would attract the mothers to come check whether their babies’ weight was OK. “Excellent idea,” I said, “what else could be done?” She added she could use that to get the babies immunized and that maybe could teach them about breastfeeding and proper nutrition. The nurse went on for about 5 minutes about all she could do. I could see how excited and motivated she was getting with every idea. They were her ideas, not mine. I just kept saying that what she said made a lot of sense to me and she kept on getting more and more resourceful, coming up with ideas about what she could do to improve maternal and child health care and what she was planning to do to tell the Barangay Captain to help her. Most of the things she said did not require additional resource but just mobilizing the community to support her. At the end of this short visit, she thanked for my help—I said, I did not do much, but that I was impressed by her plan to improve nutrition and that believed she would be a leader in community nutrition. She said “Thank you, your visit gave me hope again.” That day I learned we all need to set manageable goals and choose to make the best of any situation we are in. We get motivated when we feel competent we can do something and change a situation that is far from desirable. I also learned that helping people change their focus from what they do not have to what they do have is motivating. They see and experience they do have choice. They have the choice to choose how to perform their job and delivery quality care. They get happy.
— Dr. Elvira Beracochea on 2011-01-31
Many thanks for posting, Dr Beracochea. Your comments are so important, emphasising the ‘human-ness’ of developing people and performance. And I think you are right in observing that the intervention itself can actually be a tool of motivation. We have a large responsibility.
— Barbara Stilwell on 2011-02-10
Absolutely!I look forward to staying in touch with you and learn more about your work! Stay happy!
— elvira@midego.com on 2011-02-15