How do we motivate employees today? Before we get into that discussion, let’s digress to a basic motivational theory developed by Abraham Maslow, which he called a hierarchy of needs. He suggested that each individual has five basic needs:
Physiological;
Security and safety;
Belonging;
Self-esteem; and
Self-actualization.
Those needs must be met in a certain order, starting with the basic physiological needs at the bottom of the pyramid. These are needs that are related to survival, such as food and shelter. The next higher level, security and safety needs, relate to stability, freedom from fear, and provisions for the future. Higher still are belonging or social needs, which are satisfied when one is accepted, receives affection and love, and has interaction with others. Further up the pyramid, we see the need for esteem, which can be either internal or received from others. Status, power, autonomy, prestige, and recognition can all fulfill our need for esteem. Finally, at the highest level, actualization is achieved when one reaches his or her full potential for personal growth and fulfillment.
Maslow suggests that these needs are like a ladder. The lower-level needs of survival must be met before one can meet the needs that are higher up the ladder. He also suggests that individuals may find themselves at different levels, depending on the circumstances surrounding them that day or during that time in their life. The ultimate goal of the individual is to achieve self-actualization. The organization’s goal should be to help them do it.(1)
Maslow is not the only one to develop a theory of motivation. Frederick Herzberg, a leading motivational psychologist, suggests there are motivational satisfiers and dissatisfiers. A counterintuitive aspect of his theory is that he sees money as a dissatisfier rather than a satisfier. He suggests that it is the absence of money that motivates individuals, and it motivates them in a negative way. For example, employees who are paid the same amount every two weeks don’t perform better on payday. On the other hand, if they do something well and expect a bonus or a raise and they don’t get it, their performance may continually deteriorate. In this case, the lack of money becomes the real motivator, and it will have a longer-term effect than a bonus or a raise.(2)
Achieving improved performance is based on many other factors, including recognition, involvement, and a feeling of accomplishment. These are all components of Maslow’s hierarchy.
Here’s an example: I was once involved with an organization where I was amazed that the employees stayed. The manager was autocratic, noncommunicative, did not give raises, and did not offer a vision, and yet the turnover rate was very low. I asked the employees, including many high-level professionals, why they stayed, since the organization didn’t seem to meet the needs at upper end of Maslow’s hierarchy. The answer was intriguing. They stayed, they said, because they all got along well and supported each other when it was their turn to be called on the carpet. What motivated them was the “belongingness” and the interaction they received from each other.
In another organization, the nurses who provided direct services to patients were always grumbling about the working conditions, long hours, lack of recognition and support, no pay increases, no evaluations, and so forth. When asked why they stayed, they said it was because they were able to establish close relationships with their patients and their patients’ families. These employees were motivated by their own accomplishments, their own self-esteem, and their own way of achieving recognition from a source other than from their employer.
Let’s add more to the discussion. Daniel Pink, in his book, Drive, identifies a historical perspective from extrinsic motivators to intrinsic motivators. Motivation 1.0 was first, when humans were “driven” by food, shelter, and sex. Basic needs. Motivation 2.0 came about over time and surfaced with the idea of rewards to drive desired actions. (Frederick Winslow Taylor and Scientific Management). The way for employees to achieve motivation was to reward them with money or other external recognitions. Motivation 3.0 has evolved to include Maslow, Herzberg, and others who recognized there are other approaches to increase performance and improve productivity.
Intrinsic rewards are those that are “self-directed,” or come from the inside. As noted by Maslow et al., beyond that is the desire for individuals to contribute and achieve for themselves and for the organization.
Consider that developing a learning environment, where training, coaching, and individual development are emphasized, will result in a healthier organization. A learning environment is one where it is recognized that an individual, e.g., a provider, cannot do it alone. There are many aspects of sharing and learning that must occur. These can come through formal external programs or something as simple as a daily huddle, where clinic team members talk about what happened yesterday and what is expected to happen today. By employing a simple practice such as the daily huddle, recognition of the contributions of the staff members and encouragement for growth as part of the organizational culture will be key to motivation of the team.
These cases show us that organizations can succeed in spite of themselves. These organizations, however, are headed for mediocrity and not real success. For your practice to succeed, there must be effective ways to work with employees, to communicate, to allow them to participate, to get them involved, and to recognize the vision of the practice and how it relates to quality patient care.
Retention
What is the first thought that goes through your mind when an employee leaves? It should be “Do I need to replace that person?” Can you rearrange the steps in the process to eliminate that position?
If not, can you get a replacement with the right skill set and the right personality? As we will see, turnover has a cost. It’s not in your personnel budget, but it should be. Your practice must have a plan for dealing with replacing employees who leave, along with a budget that addresses the issue of turnover costs.
Your next question when an employee leaves should be “Why did he or she leave?” Retention of employees is essential for continuity and to control costs. One reason is that retaining employees is far less costly than recruiting. On the other hand, retaining employees is the biggest challenge to any organization in today’s mobile, knowledge-based society.
An employee is an asset and brings value to an organization. A highly trained registered nurse, laboratory technologist, or nuclear medicine technician brings refined skills to the job. They are sought after by competing organizations that offer money, involvement, a chance to advance, or an increased learning opportunity, all of which meet the employee’s higher-level needs. It is this employee who is not hard to motivate but is hard to retain.
It’s a mistake to think of retention only in terms of wages or salary. In a real sense, retention is based on giving employees the autonomy to use their skills to achieve quality patient care and giving them the tools they need to practice their skills. For example, if a new procedure is needed, give them the responsibility of leading a team that will work to create it.
Here’s another example: The receptionist may not be at the level of self-actualization, but she may want to be. A way to help employees reach that level is to give them the chance to improve their job, to make their interactions with patients more effective. Here’s one scenario: The physician is an hour late, and the receptionist is fielding complaints from the patients. “Where is the doctor? Why is she late? My appointment was over an hour ago.”
Now, what if the receptionist was part of a team that was involved in helping to solve the delay problems? What if they came up with an idea that would help smooth out the physician’s schedule? What if they proposed having a TV or new periodicals in the reception area? (We don’t have waiting rooms anymore, since we don’t want to imply that anyone has to wait.) What if they explored a better way to communicate clinical activities to the front desk? For example, are the physician and the clinical care team running late because there was a difficult procedure?
Motivating employees and ensuring their retention requires a deep understanding of their intrinsic and extrinsic needs, as well as a commitment to fostering an environment that promotes growth, collaboration, and purpose. Drawing on foundational theories such as Maslow’s hierarchy of needs, Herzberg’s motivators, and Pink’s concept of intrinsic rewards, organizations can create cultures where employees feel valued, empowered, and engaged. By prioritizing recognition, involvement, and autonomy, while also providing opportunities for learning and meaningful contributions, practices can nurture a workforce that not only delivers quality patient care but also thrives both personally and professionally. Retention is not just about minimizing turnover costs — it’s about investing in the people who drive the organization forward, ensuring they have the tools, support, and motivation to succeed.
References
Maslow A. Maslow on Management. New York: John Wiley & Sons; 1998.
Kreitner R, Kinicki A. Organizational Behavior, 3rd ed. Chicago: Richard D. Irwin; 1995.