Introduction
Methods
Setting
Study design
Conceptual framework
(Perry 1990) [75] | “An individual’s predisposition to respond to motives grounded primarily or uniquely in public institutions and organizations.” |
(Rainey and Steinbauer 1999) [76] | “General altruistic motivation to serve the interest of the community, people, state, a nation, human kind.” |
(Brewer and Selden, 2000) [77] | “The motivational force that induces individuals to perform meaningful public, community, and social service.” |
(Vandenabeele, 2007) [12] | “The beliefs, values and attitudes that go beyond self-interest and organizational interest, that concern the interest of a larger political entity, and that motivate individuals to act accordingly whenever appropriate.” |
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Rational motives
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attraction to public service, which means a “disposition to serve the public, to work for the common good, and to participate in public policy processes” [15].
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Norm -motives
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commitment to public values, understood as “a personal disposition to pursue public values” [15].
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Affective motives
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compassion, defined as “an affective bonding with identified objects, such as other members of a social category or of a political system” [15].
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self-sacrifice, meaning “the willingness of public servants to forego financial rewards for the intangible rewards they receive from serving the public” [35].
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Data collection and analysis
EJMH | NHMH | RKMH | SMBA | |
---|---|---|---|---|
In-depth Interviews | 17 | 18 | 16 | 17 |
Focus group discussions | 3 | 1 | 1 | 3 |
Group discussions | 2 | 2 | 2 | 5 |
Individual Interviews | Group discussion | Focus Group Discussion | Total | ||||||||||
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EJMH | NHMH | RKMH | SMBA | EJMH | NHMH | RKMH | SMBA | EJMH | NHMH | RKMH | SMBA | ||
a. Professionnal Profile | |||||||||||||
Doctors | 5 | 10 | 3 | 8 | 3 | 3 | 0 | 2 | 6 | 0 | 0 | 4 | 44 |
Pharmacist | 1 | 1 | 1 | 0 | 2 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 6 |
Nurse | 8 | 6 | 7 | 8 | 1 | 0 | 3 | 5 | 6 | 8 | 5 | 7 | 64 |
Administrator | 3 | 1 | 5 | 1 | 0 | 3 | 2 | 3 | 8 | 0 | 0 | 6 | 32 |
Total | 17 | 18 | 16 | 17 | 6 | 6 | 5 | 11 | 20 | 8 | 5 | 17 | 146 |
b. Managerial Position | |||||||||||||
Senior | 4 | 4 | 2 | 4 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 14 |
Intermediate | 7 | 2 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 12 |
Operational | 1 | 4 | 5 | 2 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 13 |
Total | 12 | 10 | 8 | 7 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 39 |
c. Age category | |||||||||||||
20–30 | 0 | 2 | 1 | 1 | 0 | 0 | 2 | 1 | 3 | 4 | 2 | 1 | 17 |
31–40 | 7 | 4 | 3 | 3 | 2 | 3 | 1 | 6 | 2 | 4 | 2 | 8 | 45 |
41–50 | 2 | 8 | 7 | 8 | 3 | 1 | 2 | 1 | 5 | 0 | 0 | 2 | 39 |
51–63 | 8 | 4 | 5 | 5 | 1 | 2 | 0 | 3 | 10 | 0 | 1 | 6 | 45 |
Total | 17 | 18 | 16 | 17 | 6 | 6 | 5 | 11 | 20 | 8 | 5 | 17 | 146 |
d. Gender | |||||||||||||
F | 6 | 10 | 5 | 4 | 4 | 4 | 3 | 7 | 15 | 6 | 3 | 13 | 80 |
M | 11 | 8 | 11 | 13 | 2 | 2 | 2 | 4 | 5 | 2 | 2 | 4 | 66 |
17 | 18 | 16 | 17 | 6 | 6 | 5 | 11 | 20 | 8 | 5 | 17 | 146 |
Interviews
(Focus) group discussions
Document review
Analysis
Ethical considerations
Results
What motivates health workers?
Intrinsic motives
“I love my job. I chose deliberately to work at the emergency unit. I love working at the emergency unit. I am totally engaged. Handling serious medical emergencies is a motivation in itself”. EJMH 38, Doctor.
“I am frustrated because my salary does not compensate my efforts. However, nursing is a noble profession that has nothing to do with financial incentives.” NHMH 30, Nurse.
“As for me, this [participating in the quality contest] was a great pleasure. I enjoyed that. This was not for the sake of doing good for others, but it was mainly for my own satisfaction… My objective was to accomplish this managerial task and to prove to myself that I can do this. This is why I was striving to make that effort.” NHMH 10, Doctor.
“I participated in several ‘medical caravans’. This was for me just pleasure. I just enjoyed it. It was not about the feeling to do good for others. I gained patient recognition and above all I felt self-efficacious toward patients”. NHMH 31, Doctor
Extrinsic motives
“We need that leaders recognise our performance: 6.000 deliveries a year! We need that they congratulate us”. SMBA 06, Midwife.
“We are satisfied when our effort is acknowledged by others (patients).” NHMH 13, Doctor
Esteem from supervisors was highly valued and led some health workers to feel guilty when they do not meet their supervisors expectations.“When people came to thank me, because they get well because of me, I feel that I am the happiest man in the world. Because, I hate to walk around in the city and that people bad mouth me: “This obnoxious doctor did not treat me well”. I cannot tolerate this.” SMBA 18, Doctor.
“I feel ashamed, if I did not do the work my superior ask me to do”. SMBA 05, Nurse / senior manager.
“Here in the public sector, there is a certain liberty, work is fluid. This is why I choose the public sector. I avoided the private sector where I could earn twice or thrice my salary, but I dropped the economic reasons, and chose to get the minimum wages offered in the public sector, because I chose to be free, because there is less hierarchy than in the private sector or in the university teaching hospital, where the doctor in chief could sanction me severely and even stop my salary.” NHMH 2, Nurse.
“Why am I staying at the public sector? I can earn three times my salary in the private sector. Well, I have a six years old daughter, I need to enjoy her company.” RKMH 3, Doctor.
How is PSM defined?
Affective motives
Staff were expressing compassion with the vulnerable and underprivileged members of the population. They were placing themselves in their situation and showing empathy toward these patients and their families. This even led some of them to help patients pay user fees.“Patients are important for me because I got sick. So, I sense what the patients are feeling. My family members, my daughter and my grandmother got sick. So, I feel the pain patients are suffering from. I can feel their suffering. ” SMBA 35, Nurse.
Respondents explained that serving the underprivileged and caring for the poor is one of the reasons that kept them working in the public sector.“One day, a citizen came to pay for laboratory tests for his daughter who had fever and he could not afford to pay the fees. I added the missing amount from my own money. Not every day, but often, I bring small change to help citizens who do not have the full amount. My wallet is always opened.” NHMH 29, Revenue officer.
The notion of self-sacrifice was mentioned but not often. Some respondents expressed the importance of serving the patient compared with the financial rewards. Some health workers may forgo their own health needs in order to serve patients in what we call an “escalation of commitment”.“Here, I work a lot with vulnerable citizens. It is a reward in itself to serve poor patients. It is my source of motivation”. RKMH 3, Doctor
“Sometimes, I think I sacrifice a lot in order to serve others. We cannot justify this. It is not reasonable. It is 16h30 and I just ate! I do not eat. I lost weight, I got tuberculosis, I had cervical pain, arthralgia, backpain, a sciatica. I had thoracic pain because I suffered from a pleural effusion. Is it logical to suffer in order to treat patients?” EJMH 38, Doctor Emergency Unit.
“The cardiologist is highly concerned about patients. She is worried about them. Even if her shift ends at 4H30 pm, she keeps coming back to the hospital to check on them, even during weekends. She is continuously in contact with us by phone to check on her patients, their test results, their condition. She is omnipresent. If a patient is in a bad condition, she returns to the hospital. She does not have to, but she keeps coming back even during weekends. She is so consciencious and keeps checking on her patients. This is why she got sick!” EJMH 24 nurse.
Norm-based motivation
“A love for our country, love of our territory, love of the land of our ancestors, love of neighbourhoods, we love to leave a suitable environment for our siblings.” EJMH 8, Administrator.
Some of the health workers who expressed a commitment to public values described how that led to prosocial behaviours, such community volunteering.“We are Moroccans serving Moroccans. I do not feel proud if I could not serve adequately our citizens. We are an integral part of this institution. The reputation of this institution is our reputation. We are a small cell within a large cell that is the Ministry of Health. We work with devotion”. NHMH 16, Doctor.
“We care for the public service. We organized a community action in the former hospital location on a voluntary basis, without any instruction from the hospital administration. We noticed that the hospital garden was deteriorating. So, with other friends and union representatives, we refurbished the garden.” EJMH 23, Nurse.
“I worked for non governemental organisations, doing medical caravans with doctors in rural areas in Walidia. I started working for NGOs not affiliated to any political party in 1979-1980. I believe that working for NGOs educates young people. We grew up doing medical caravans, serving the population, we worked with doctors till 8 or 9 pm.” EJMH 41, Nurse.
Rational motives
“As the chief of this department, the most important thing for me is when I am involved in decision-making. I do not only report on problems. As a leader, I suggest solutions that get always approved by the hierarchy.” EJMH, 12 Nurse intermediate manager.
PSM was expressed similary by respondents from both poor- and high-performing hospitals. However, in poor performing hospitals, staff said they were suffering from psychological distress and feelings of guilt because of their inability to perform their job adequately and to ease their patients suffering.“This title [Chief Nursing Officer] allows me to commit to my job. As a chief nursing officer, I have an authority on all nurses in the hospital. Sincerely, this title motivates me because I am solicited by staff to provide them with the necessary support. This is true for both doctors and nurses. I am fully satisfied when my opinion is listened to and taken into consideration. This makes me more motivated to fill this position that allows me to serve people.” EJMH1, Senior manager, Nurse.
This influenced negatively their well-being.“We lose patients stupidly because of a lack of material. There is no material to work with. You see patients die in front of you and you do not have necessary tools to save them. These conditions are beyond our control.” SMBA 43, Doctor
“When you do not have necessary material to work with, you are in trouble! It is not only a constraint, but a source of suffering. Instead of relieving patients’ distress, it is us who get stressed.” SMBA 45, Doctor
What contributes to public service motivation?
Family education
“I do not take bribes. I have an ideal about the role of doctors in society. Their role is not limited to being a care provider at the hospital. They should get out to the community, sensitize the population during health education sessions. I feel satisfied when we organize a round table with practitioners and local representatives, when we organize medical caravans, when we circumcise children for the sake of God. I learned these principles through my parents’ education. When we were young, we were educated to help people, to help others, neighbours, friends, siblings and family members. I cannot explain these things, I do not know if it is genetics, but we learn that we do not live alone but in a society. We depend on each other, we belong to a society, we live with neighbours and people. Everybody is leaning on others, like dominos.” SMBA 40, Surgeon
Military service
“Every health worker, specifically males, should do military service, as I did. At that time, I went to Al Farssia, a remote area in the Moroccan territory in the middle of nowhere. I used to stay there between two to three months and then would go back to town for a short period of time. Every time I went back to that region, I recognized the true meaning of life and the true value of things, when I compared urban life to these remote areas.” NHMH 32, Doctor/Senior Manager.
“I was asked to join the military service. … I believe that in my country, we are more effective if we serve the poor, if we work for the interest of the most vulnerable citizens. The experience I had in the medical service in the military affected me a lot. It has shown me that Morocco needs more faithful and serious health workers.” SMBA 18, Doctor
Volunteering
“From 1970 to 1980, I was part of an NGO doing medical caravans with physicians in rural areas. Volunteering educates people. When you grow up volunteering, you will be loving to serve the population. I worked for 8 to 9 hours a day without being paid. I did it for the sake of God without waiting for external rewards. EJMH 41, Nurse.
Professionalism
Their commitment to serve the patients is integrated within their professional identity but also with their religion.“I love my job. I cannot neglect my job. This is how I was educated and taught in the first place. I cannot let down a patient, even though I know that this (quality of care) does not depend only on me. I cannot. I try to help patients even if they are from other departments. I call the surgeon to deal with a patient with a suspicion of appendicitis, even if it is the job of the physician at the emergency department.” SMBA 24, Nurse,
“ ‘Citizens’ means for me ‘professional conscientiousness’ [in Arabic, damir]. I have to serve them conscientiously. It is important part of my personality. I do not like to fail to properly perform my duty. My money will be then halal [Compliant with what is permitted in Islam]. NHMH 13, Nurse
Religious beliefs
“He [the patient] praises God for you, he says nice prayers! “May Allah [God] be pleased with you. May Allah be merciful to you. May you be covered by the grace of God”. At such moments, I feel reassured and relieved during my night shift. Then I go home fully satisfied.” SMBA 35, Nurse.
“When serving people, you earn ajre (divine rewards) from God, which is far better than money.” EJMH 18, Administrative staff.
Our analysis indicates that religious beliefs may underlie public service motivation to the extent that these beliefs contribute to an altruistic and compassionate attitude towards patients as well as to commitment to public values.‘This is between us and God, Glory be to Allah. It is between me and God who created me. We do good deeds when serving patients because we need ajre [divine rewards]. We do not know what might occur to us in the future. We seek ajre from God. He is the only one who will reward us for our effort”. SMBA 7, Nurse.
Our data show that these religious beliefs are closely aligned to the professional sense of responsibility and duty, to the attraction to public service and to compassion.“There is a religious element that plays a role in my motivation. We have to make our money halal [meaning in compliance with Islamic rules]. This means I have to work, to serve people. We are equal to them. We are all Muslims. They [patients] are our fellow countrymen, our fellow citizens. We are obliged to give them back what we owe to our country.” NHMH 11, Surgeon, Intermediate-level manager.
“I am pleased when I treat patients decently and they pray God for you. I am pleased when I see that patients are happy and in a good state.” SMBA 35, Nurse
We found that for many health workers we interviewed, PSM and religious beliefs and values are intertwined. They express their altruistic and compassionate attitude towards patients as a spiritual personal obligation. When serving patients ethically and altruistically, they expect to receive intangible and divine rewards (in arabic hassanat’ or ajre). They also frame this as a commitment to public values such as equity and patriotism.“Have mercy on those on earth, the one in Heaven will have mercy on you ... This is our real profession, to love others. I am a human, I can also become sick. We are all patients”. SMBA 17, Nurse
When discussing PSM, health workers also referred to the ‘Hadith’, the sayings of the Prophet Muhammed, when they justified why they are committed to help patients and the underprivileged.“In Arabic terms, we do this because we need to make our salary “Halal.” [Halal means compliant with Islamic rules]. “Thank God.” We said this because it is very important! We must make sure that our salary is halal before God and our own conscience. There is nobody watching over us, whether we came at 8 am in the morning or not”. EJMH 9 doctor
“[In the Prophet Muhammed sayings and teachings], the prophet said “Who served other muslims, is rewarded like someone who stayed a month praying in this mosque.” This explains why I came early at 8h30 am. Sometimes, when I come late to work, I stay late in compensation, hoping that this way, God will help my siblings.” NHMH 11, surgeon
“We are muslims. Then, satisfying the need of others is essential [referring to ‘Hadith’ ]. I feel satisfied and I enjoy that. We have an ideology that dominates our behaviour as muslims. We are not compensated directly but we get rewards later in other circumstances. Sometimes, I might serve and help this old lady we have just seen. By doing so, I might be helped in the future when I will experience the same situation.” NHMH 7, Doctor.