This article looks at various theories of motivation and attempts to assess whether the present system of remuneration for community pharmacists is deficient or flawed and whether other systems would be likely to enhance motivation
Successful remuneration models should provide the correct incentives and avoid the wrong disincentives for community pharmacists and for patients. This could be expressed as a principle and an objective, namely, that a remuneration system should provide a correct and acceptable motivation for community pharmacists to produce an effective, efficient and value-for-money care service for their patients. However, such motivation is not solely provided by pay.
It is difficult to resolve what single motivation factor could be used to make community pharmacy provide pharmaceutical care as now practised in hospitals in Britain and increasingly in community practice in the United States, Canada, New Zealand, Ireland and many other countries. Owners of businesses would claim that a more realistic (in their view) return on capital invested, a higher percentage margin on the products supplied together with higher fees to enable more than one pharmacist to be employed are required. The practising pharmacist would probably wish for an increased status within the primary health care team and a more direct application of the full provision of pharmaceutical care to each individual patient. It is by no means certain that the latter can be so motivated in such a way even if the contractor's return on capital invested was increased or if the percentage margin on the products was also increased. The content of the National Health Service contract would also have to be altered so that the contractor was obliged to provide new services, the execution of which motivated the pharmacist who provided them.
Motivational theories can be divided into two categories: content and process. These terms have been used in psychological studies of motivation and are described in relation to professions (and others) by Adams.1 Content theories assume that all individuals possess the same set of needs. Thus these theories tend to be prescriptive, since, by assuming people have similar needs, they are also recommending the characteristics that ought to be present in all jobs. Process theories, on the other hand, stress the differences in people's needs and focus on the human cognitive processes that create differences between individuals.
There are several content theories:
|
Maslow's theory The simplest and most influential is that outlined by Maslow.2 He suggested that there is a hierarchy of needs up which people progress. When an individual satisfies a need at one level in the hierarchy, it ceases to motivate his behaviour; instead, the individual is motivated by the need at the next level of the hierarchy. For example, at first, individuals are motivated by physiological needs such as alleviating hunger and thirst. If these are met then security needs such as shelter and protection become the major influences on an individual's behaviour. These are termed deficiency needs. Figure 1 shows that this progression ultimately leads to behaviour motivated principally by the needs (termed higher order needs) to realise one's full potential, which Maslow termed the need for self-actualisation. Maslow suggested that, owing to the uneven distribution of satisfying work, only a very small proportion of the population reached this level. Thus, self-actualisation is for most individuals a need that will motivate their behaviour throughout their lives.
|
Figure 1: Maslow's hierarchy of needs |
The Existence, Relatedness and Growth theory The theory known as the Existence, Relatedness and Growth (ERG) theory4 provides reasonably reliable methods to measure needs which it suggests Maslow's theory does not. The ERG theory, proposed by Alderfer,4 suggests that an individual's needs can be divided into three groups:
The ERG theory differs from that of Maslow in several important respects. Maslow's theory proposes progression up a hierarchy while Alderfer suggested a continuum from existence needs to growth needs. He argued that it was possible to move in either direction. This means that, if growth needs become difficult or impossible to meet, frustration regression occurs, causing individuals to concentrate on fulfilling their relatedness and their existence needs. Unsatisfied needs, therefore, become less rather than more important. Maslow proposed the opposite.
In the present context, if community pharmacists are prevented from satisfying their growth needs they will concentrate on complaining about existence needs, including perceived low or unsatisfactory pay. This has been partially confirmed in a recent study by Willet and Cooper,5 who found that perceived low remuneration was a cause of stress in community pharmacy.
Another notable difference between these theories, as far as pharmacy practice and remuneration are concerned, is the importance to individuals of satisfying perceived needs. Whereas Maslow argued that when satisfied a need becomes less important to an individual, research based on Alderfer's theories has found that existence, relatedness or growth needs actually become more important when satisfied.6 This means, for example, that team working arrangements and fair wages (as agreed between worker and employer), which satisfy relatedness and existence needs, can continue to motivate employees and are not necessarily superseded by growth needs.
This conclusion is, on the face of it, in direct contradiction to the conclusion drawn in Maslow's work2 as regards community pharmacy. However, this need not be so.
If pharmacists are not satisfied that their existence and relatedness needs are being met in community pharmacy practice at present, then frustration regression will cause them to concentrate on pay and working conditions as well as or in place of self-actualisation or growth needs.
To pursue this line it is necessary to explore the possibility that a refinement of Maslow's and Alderfer's approaches by Mumford7 in 1977 may have produced a more conclusive answer to the motivation required to satisfy the current perceived frustration (and presumably, unfulfilled needs) of community pharmacists.
Mumford's theory Mumford suggested that workers have the following needs:
Mumford assumes that employees do not simply see their job as a means to an end, but have needs which relate to the nature of their work. If this assumption is correct in community pharmacy practice, then the frustration regression apparently being experienced may be due to the nature of the work. It may well be that community pharmacists do not see more or higher pay for an expanded role as their main need, but rather that the nature of the new or expanded role will better satisfy their knowledge needs, control needs, psychological needs, task needs and their moral needs, and that higher pay will be an expression of need fulfilment rather than meeting only an existence need.
Herzberg's two-factor theory A further content theory, known as Herzberg's two factor theory,8 is worth considering as it may be directly relevant to community pharmacy, since the original work was carried out with such professional groups as accountants and engineers, whereas the previous theories used manual workers as the research sample.
The original research used what is known as the critical incident technique. This involves asking interviewees to talk about occasions when they felt either particularly satisfied or particularly dissatisfied with their jobs. Two sets of incidents emerged from this process. The first involved achievement, advancement, recognition, autonomy and other intrinsic aspects of work. Because they represent sources of satisfaction, they were termed "motivators". The second set of incidents concerned working conditions, salary, job security, company policy, supervisors and interpersonal relations. This set was termed "hygiene factors". These hygiene factors were described as sources of dissatisfaction by the sample interviewed.
It would appear from this study, therefore, that job satisfaction and job dissatisfaction seem to be caused by a different set of factors. The presence of motivators in the workplace caused enduring states of motivation in employees. Their absence, however, did not lead to job dissatisfaction. Hygiene factors, on the other hand, produced an acceptable work environment, though not an increase in job satisfaction or involvement with the job. Their absence (eg, perceived low pay), however, caused dissatisfaction. Thus motivators reflected people's need for self-actualisation, while hygiene factors represent the need to avoid pain.
This theory goes further, however. As well as describing employees' needs, it indicates how people's jobs can be redesigned to incorporate more motivators (Table 1).
Table 1: Herzberg's principles of vertical job loading |
|
| Principles | Motivators involved |
| Increasing employees' autonomy while retaining accountability | Responsibility and achievement |
| Increasing employees' accountability for their own work | Responsibility and recognition |
| Providing employees with a complete natural unit of work | Responsibility, achievement and recognition |
| Making performance feedback available to employee | Recognition |
| Introducing new and more difficult tasks to employees' work | Growth and learning |
| Assigning employees specific or specialised tasks at which they can become expert | Responsibility, growth and achievement |
Later studies have suggested flaws in the theory and in particular the independent effect of motivators and hygiene factors. At least one study9 has demonstrated that both can be related to job satisfaction and job dissatisfaction. It has been suggested that because professionals were used (accountants and engineers), a middle-class bias exists in the Herzberg two-factor theory.
This last fact, however, would not necessarily invalidate Herzberg's theory as far as community pharmacists are concerned since, generally, community pharmacists are regarded as middle class.
All process theories have in common an emphasis on the role of an individual's cognitive processes in determining his or her level of motivation.
Equity theory The major process theory, known as the equity theory, assumes that the most important cognitive process involves people looking around and observing what effort other people put into their work and what rewards they receive, and comparing the ratio of these with their own efforts and rewards. People can also compare their energy:reward ratio with one which they experienced at another point in time (ie, things are not as good or as bad as they used to be). Equity theorists assume that this social comparison process is driven by our concerns with fairness or equity. This certainly appears to be relevant to community pharmacy since The Pharmaceutical Journal frequently publishes letters to the editor containing complaints about the fairness and/or equity of community pharmacists' effort, knowledge and energy:reward ratio compared with those of plumbers, hospital pharmacists, general medical practitioners and, in particular, dispensing doctors, and how, in the old days, community pharmacy was more rewarding in terms of job satisfaction and pay.5 The writers of these letters and articles perceive others as giving, at least, a similar input and often one which has less in terms of effort, qualification, skill level and seniority, but receiving dissimilar outcomes in terms of pay, advancement and fringe benefits. They perceive that the ratios now favour the others. Therefore, they regard themselves as underpaid and thus they experience inequity, which is assumed to be a sufficiently unpleasant experience to motivate changes in either their behaviour or their perceptions, or both.
Thus, people perceive effort and reward not in absolute terms but in relative terms.10 Community pharmacy contractors, however, have to endure two comparative ratios: they compare themselves with other retail traders and with other health care professionals. There is a suggestion that the current remuneration system requires them to function as health care professionals but does not assist them to survive in the market place as retailers. In the longer term this conflicting situation may not be sustainable.
It is true that community pharmacists perceive their ratio to be inequitable and have striven to change their behaviour.11 For example, they wish new and expanded roles not only for their own satisfaction but also to improve the care given to patients. It may also be that they presume the latter will change patients' and the public's perception of their usefulness and, as a consequence, their ratio of effort to reward will become comparatively more equitable.12
|
VIE theory One process theory which could be used by the Government to assist in this process is the Valence, Instrumentality and Expectancy (VIE) theory. The origin of this theory is a 1964 study by Vroom.13 This study argued that what was crucial to motivation at work was the perception of a link between effort and reward. Perceiving such a link could be thought of as a process in which the community pharmacist calculates first whether there was a connection between effort and performance (expectancy), then the probability that valued rewards (valences) would follow from high performance (instrumentality). Vroom argued that the motivational force of a job could be calculated mathematically if the expectancy, instrumentality and valence values were known (see Panel).
|
|
It is not known if the Government has considered introducing formal motivating procedures to improve NHS pharmaceutical practice. The current reliance on a simple, subjective, economic measure which could be expressed as "if enough of them want to do it, then the rewards they receive must be adequate" does not seem designed to improving the outcomes in health care objectives where medicinal products are used.
There are theoretical models available that could be used as described in this paper. However, it is clear that mechanisms that would motivate professional pharmacists may not be compatible with those that motivate the management of corporate companies. It is for this reason that a pragmatic model may need to be available and this has been explored in a recent thesis.14 It is possible that such a model could meet the motivation needs of all of the stakeholders in the NHS primary care pharmaceutical service.
This paper is an extract from an MPhil thesis, "Remuneration of community pharmacy in Scotland" (Aberdeen: Robert Gordon University). Although the project was sponsored by the Scottish Pharmaceutical General Council, and its assistance is gratefully acknowledged, the views and opinions expressed in this extract and in the thesis are those of the author and do not in any way represent the policy, views or opinions of the council, its standing committee, or any of its members or officials.
Professor Calder is visitng professor at the University of Strathclyde and honorary professor at the Robert Gordon University, Aberdeen
There is an error in Figure 1. The fifth box should have been titled "physiological" not "psychological" needs