The impact of motivation on aggregate resignation : Case study of public health sector in Oman

This study examined the motivation effects of organizational commitment (OC) and organizational engagement (OE) on the relationship between human resource (HR) practices (motivation of staff, empowerment of staff, goal-setting motivations, safety motivations, environmental motivations) and resignation intention. The study covered almost 95% of Al Buraimi hospital’s foreign staff (325 people) (not including Omani staff) in Sultanate of Oman. Each completed survey was treated in a fair and confidential manner without mentioning the name or position of the staff members. We made sure that every staff member participating knew about these procedures of collecting and gathering data. It was found that all the variables used to measure HR practices in terms of motivation factors have significant effects on OC and OE. However, multiple regression analyses indicated that career management and job control have a significant influence on resignation intention. OC and OE have major effects on the relationship between HR regarding motivation issue and resignation intention.


INTRODUCTION
Managing people is an issue for any manager.This process has been discussed in a lot of theories across the history of management such as content theory, Abraham Maslow's hierarchy of needs theory, Herzberg's twofactor theory and Alderfer's ERG theory (Simons, 1987).Most theories are about motivation, which is the key for success not only in organizations but also in our day-today lives.Another approach of these theories such as Skinner's reinforcement theory focuses on external factors to understand people's motivation (Buchbinder and Shanks 2007).All these theories attempt to explain and identify the sources of motivation influencing individuals' behaviours and how to motivate them to behave in desirable ways.The subject of motivation has a very important place in psychology owing to its role in explaining the behaviour of human beings.
This report discusses one of a common workplace problem which lies in the area of basic motivation.We support our report by discussing some motivation theories, which help us to analyse and explain the issue as well as using a survey to evaluate the situation and interpret data according to these inputs.Our motive for writing this issue is to help top management in dealing with this problem by providing recommendations about the source of motivation in order to improve the quality of service in our organization.
The labour force has particular structures especially in the health sector.These specific features of workforce can be motivated to face many of the persuasive challenges facing healthcare today (Ratanawongsa et al., 2006).The healthcare institutions are faced with internal and external pressures that should be met effectively with appropriate adjustments and development of the workforce.Development process is a crucial part of any health organization (Dubois and Singh, 2009).
Al Buraimi hospital in Oman is a very sensitive place in terms of providing a high quality of service because it deals with people's lives.So it is vital for any health care organization to have considered the factors necessary to be successful, and the main factor here is to have skilled manpower.The Ministry of Health in Oman re-established this hospital in 1994, with very new medical equipment and capacity of 150 beds.The importance of this hospital is due to it being the only one in the Al Buraimi governorate, which according to the 2003 census has a population of 76,838.Al Buraimi City is located in Northeastern Oman, about 435 km from Muscat, on the borderline of the United Arab Emirates.It is very close to the city of Al Ain in the UAE.

THEORETICAL BACKGROUND
Over the past years, a huge number of theories have been developed attempting to explain and identify sources of motivation, which move the energy and power inside us to exhibit particulars behavior particular behaviours.All these theories suggest different groups of motivational sources; some of these groups are ranked as a hierarchy, others are proposed as developmental stages and most of the other theories have no fundamental process of transfer from one source to another.
In this report, we describe the different theories and apply them to our issue; we go through the famous theories created by researchers such as McGregor (1906-1964), Abraham Harold Maslow (1908-1970), Clayton Paul Alderfer (1972), J. Stacy Adams (1963-1965) and some other scientists dealing with motivation theories.The purpose of applying these motivation theories is to analyse how our issue can be solved by these theories.

Maslow's hierarchy of needs
This theory focuses on how to differentiate between drives and motives, and Maslow proposes a hierarchical theory of human needs.According to Maslow's theory, we have nine innate needs or motives: biological needs, Badi 523 safety needs, affiliation needs, esteem needs, the need to know and to understand, aesthetic needs, the need for transcendence, the need for freedom of enquiry and expression, and self-actualization needs.Maslow ordered a hierarchical theory of needs in such a way that he set up all the basic needs at the bottom and the highest needs of self-actualization and transcendence at the top.Maslow specialized in humanistic psychology and he strongly believed that "people are not controlled by mechanical forces (the stimuli and reinforcement forces of behaviorism) or unconscious instinctual impulses of psychoanalysis alone".When we apply this theory to our issue we can notice that medical professional staff have an anxiety about the educational future of their kids because there are no good private schools in Al Buraimi; according to Maslow's hierarchy, they will desire to look for more trusted private schools that ensure a professional education for their kids, which are available in the neighbouring city of Al Ain.When they have realized this they will desire to be in Al Ain city, near the private schools for their kids and so on.This desire will develop step by step, until they convince themselves to resign at the first chance of a job in Al Ain city.

Existence, relatedness and growth (ERG) theory
In his existence, relatedness and growth (ERG) theory, Clayton Alderfer emphasizes that it is more realistic to cut down Maslow's hierarchy of needs to three categories instead of five needs.The first category is existence needs, which are related to Maslow's biological and safety needs.For example, the medical staff need to have economic safety, which means here to have a good salaries which can effectively meet their increasing demands.Also, when they give high standard of education to their children, they will have peace and tranquility.The second category of relatedness refers to affiliation and esteem needs.Finally, growth needs are those that involve self-actualization and self-esteem needs.ERG theory says that those three categories can be activated at any one time.Also, Alderfer involves a "regression hypothesis" in contrast with the "progression hypothesis" of Maslow.

Acquired needs theory
The acquired needs theory, proposed by David McClelland, emphasizes that "an individual's specific needs are acquired over time and are shaped by one's life experiences".According to this theory, most wants and needs seem to be ordered by achievement, affiliation or power.A person's motivation and effectiveness in certain job functions are influenced by these three needs.
McClelland's theory is sometimes referred to as the three-need theory If medical professional staff have a high need for achievement, they will strive to do better in terms of performance or to be more efficient in order to achieve self-set standards.Because the high-risk environment works for them, they need to know about the results of their work, and need feedback in order to measure and monitor the progress of their achievement.
According to the acquired needs theory, everybody naturally needs affiliation, and medical professional staff would rank this need as being very important because most of the time they work within a team; so they look for harmonious relationships with other parts of that team.
Medical professional staff are always dealing with people; everyday they meet many patients, so they need power to influence those patients or have an impact on them.Sometimes doctors treat their patients by directing them to specific behaviours rather than prescribing medicine.

Frederick Herzberg's theory (hygiene factors and motivators)
Motivation can also be considered as a social influence process (Huczynski and Buchanan, 2007).This is emphasised by Frederick Herzberg, regarded as a pioneer in motivation theory.He was the first to develop the concept of "job enrichment".His findings are based on interviewing group workers to identify and summarize what factors influence job satisfaction and dissatisfaction; according to these interviews he developed a two-factor theory of motivation.Herzberg calls them "motivation factors" and "hygiene factors".Motivation factors are "aspects of work which lead to high levels of satisfaction, motivation and performance, including achievement, recognition, responsibility, advancement, growth and the work itself".Hygiene factors are "aspects of work which remove dissatisfaction, but do not contribute to motivation and performance including organizational policy, supervision, interpersonal relations, working conditions, and salary".According to Herzberg's theory, the motivation factors are related to long-term positive effects on job performance while the hygiene factors essentially develop only short-term changes in job performance, which soon return back to its previous level.
In terms of the medical professional staff at Al Buraimi hospital, we can classify their problems as hygiene factors rather than motivation factors.According to the theory, if hygiene factors do not exist in the job environment, it can lead to job dissatisfaction, but their existence does not motivate or create satisfaction.In our case, the absence of hygiene factors is clear and this contributes to the resignations of medical professional staff.For example, if we look at the variance in the salaries of the Al Buraimi and Al Ain hospitals, we can notice a huge difference; Al Ain hospital salaries reach up to four times those of Al Buraimi hospital.This creates job dissatisfaction for medical professional staff, but if this issue were solved it would not necessarily make staff satisfied; it would be a short-term solution.

Terms of reference: the issues
Since this hospital was established it has experienced a perennial shortage of medical professionals; this is not because the Ministry of Health in Oman does not provide the hospital with them but because a lot of them suddenly resign.During the last two years, the percentage of medical professionals resigning each year increased dramatically; according to the human resources (HR) department in the hospital, this percentage reached 20% of the manpower within the hospital.The administration of the hospital was suffering because of this problem.As mentioned above, this hospital provides health care services for about 76,838 people, so any lack of manpower creates serious problems, beginning with complaints from outpatients because they do not get the appropriate diagnoses (Outpatients Records in OPD, 2008).For instance, if there is a pregnancy case that is supposed to be checked in the obstetrics and gynaecology department, they may refer it to a general clinic because they do not have enough specialist doctors in gynaecology.Sometimes patients do not get any diagnosis or treatment at all because of the huge number of them and the limited doctors available.
This hospital is supposed to provide health care services not only for Al Buraimi city people but also for those who are in transit.Because of the location of Al Buraimi city on the border with the UAE, a lot of passengers use it as a transition area when crossing from inner Oman to the UAE and vice versa.These extra people overload the hospital.
The Ministry of Health, attempting to cover the shortage of medical professional, often recruit foreign doctors with short-term employment contracts because there are no more Omani doctors available for local contracts.However, according to civil service rules and procedures in Oman, this type of contract is only allowed to be used under exceptions from the Board Management of Ministries Council.Most of the time those doctors have visiting visas, which means they cannot be in Oman for more than six months but, because of the urgent need for them, the ministry has agreed to recruit visiting doctors with visas and negotiate with emigration authorities to extend their visiting period.Although this procedure helps somewhat, the problem is that most of these doctors are not specialists, so it is a very weak action and the main problem is not solved yet.Recruiting outside medical professionals takes time and entails a very long procedure-placing advertisements in foreign newspapers, waiting for candidates, and then interviewing them depending on their qualifications, and so on.This procedure takes more than four months, which is very long period considering the urgent need for them.The Ministry of Health has added a new provision for contracts of employment for all medical professionals, especially for those who will be working in the Al Buraimi governorate; this new provision in the contracts adds that, in case of resignation, the employee has to give the ministry one month's notice and this action is obligatory.

METHODOLOGY
A survey and interview were used in this investigation and, since they vary in the response rates they generate and in their coverage and accuracy, we compare between the results from two methods.According to the Human Resource Department, the total number of foreign staff (not Omani nationality staff) is 206.120 staff participated in the survey (the final number of respondents is 113).The interview was conducted for 56 participants, among whom 24 have resigned.The scope of the survey here is more expanded than the interview; the reason for this is that we faced difficulties in finding people who had resigned -sometimes their addresses had changed, their phones were switched off or they did not reply to emails, which limited our process.

FINDINGS (ONLINE INTERVIEW)
We tried to gather details from HR records about doctors who had recently resigned, such as their addresses, phone numbers and emails.We emailed them and asked them to give us information about the reasons for their resignations; some of them replied and others did not.The limitation of this process was that a lot of those staff had not given HR any details about where they would be.The main objectives of these interviews were to analyse and identify the reasons for their resignations, and go through motivational factors.The main findings of the online interviews are as follows: 1.As soon as the doctors reach Al Buraimi City they try to get approval to have a UAE visiting visa.2. When visiting Al Ain city in the UAE, which is about 10 km away from Al Buraimi, they notice the different life there and how it is more developed than Al Buraimi, which motivates them to be there instead.3.They ask for any opportunity to work there because the salary there is three times more than here.4. They want private schools with high standards of education for their kids, which are available in Al Ain city; for example, there are Indian private schools, Pakistani private schools, multi-language schools, etc., while there is only one Arabic private school in Al Buraimi. 5.The standard of life in Al Ain is very high; the city has a lot of hypermarkets and supermarkets, while there is just a small market in Al Buraimi, which most of the time has no stock.6.With regard to entertainment, in Al Ain there are parks, green spaces, hotels, cinemas, kids' play areas, nice restaurants, etc., while there is none of these in Al Badi 525 Buraimi.
Those motivational factors were the main reasons for doctors resigning and moving directly to work in Al Ain instead if any opportunity came up.The easy and comfortable recruitment procedures of the health authority in the UAE and the environment of the job are also a very important factor.

Employee's motivations survey
The second part of the investigation was to conduct an "employee motivations survey" for the medical professionals still working in Al Buraimi hospital.Some of these employees have been in service for more than twelve years; others are very new; our target groups were the new employees and the old staff to know the reasons for their loyalty to Al Buraimi hospital.The main purpose of the survey was to discover the explanations and the root causes of this problem.The survey covered almost 95% of the hospital's foreign staff (not including Omani staff).Each completed survey was treated in a fair and confidential manner without mentioning the name or position of the staff member.We made sure that every staff member participating knew about these procedures of collecting and gathering data.

Summary of findings
The answers to the employee motivations survey were the keys to knowing the sources of the lack of motivation.We divided our employee motivations survey into five parts to help us gather and analyse the data: 1. What motivates the staff 2. The empowerment of staff 3. Goal-setting motivations 4. Safety motivations 5. Environmental motivations We collect the data and analysed them using a computerized program to give us results as percentages.We can notice from the results (see appendix B) that, naturally, there is not a person in the world that could not use more money.So we can say here that money is a factor that can never be ignored and it is an incentive for people.In general, money is a good way to motivate employees.
The section on the empowerment of staff showed that this is good in the hospital; this empowerment is basically inherent within the nature of a medical professional's duty.So a lot of staff members were satisfied about this point.Obviously, there is no lack of motivation here and the issue seems to be elsewhere.In the third section, which is about goal-setting motivations, we applied the goal-setting theory proposed by Edwin Locke (1968- 1975).This theory establishes four main propositions: challenging goals, specific goals, participation in goalsetting and knowledge of results of past performance.
In sections four and five we relied on content theories of motivation, which are focused on the goals to which we aspire; our research here applies the theory proposed by Abraham Harold Maslow (1908Maslow ( -1970)).

Analysis
Based on the interviews we have done, we discovered some findings, which are mentioned above; these findings are the keys to getting more knowledge about the medical professional staff members' motivational problems, which lead them to resign and look for another place to work in Al Ain city.After combining the result from the employee motivation survey, which is attached in appendix A, and the results we collected from the interviews, which are attached in appendix B, we transferred these data to percentages and converted them to a diagram format to be easy for us to analyse and to set up some recommendations, and also to make clear the meaning of these data to the readers.

What motivates staff?
Here we addressed some questions that indicate the variance in the salaries of Al Buraimi hospital and Al Ain hospital.The diagram shows that 84% of the medical professionals consider salary to be a very important reason to resign and move to Al Ain hospital (Figure 1) This percentage is very big and, according to Herzberg's theory (hygiene factors and motivation factors), it comes under hygiene factors.Medical professional staff believe they are not compensated well, so they are unhappy to work in Al Buraimi hospital.

The empowerment of the staff
According to the results of the survey, 84% of staff  members believe that the administration of the hospital gives them some autonomy in their job descriptions (Figure 2); therefore, there seems to be no problem in terms of empowerment.On the other hand, 60% of medical professional staff feel that the administration of the hospital does not have an effect on their decision when finding appropriate solutions for any problems a professional may face (Figure 3).Also, the clarity of the tasks given by the administration are simple and understood; as we can notice from the diagram, 89% of medical professional staff have no problem with this point.

Goal-setting
Figure 4 shows that around 13% of medical professional staff strongly agree that they participate in goal-setting.This number is quite small and it indicates the existence of participation problems.This may lead to dissatisfaction about the goals of the organization, which may make the staff unhappy and can be considered a reason for their resignations.In addition, it may lead to low performance and affect the efficiency of the organization.

Feedback on performance
Figure 5 shows that 67% of medical professional staff  agree or strongly agree that they get feedback about their performance.When we were going through the feedback procedures at the hospital, we found that they do not send regular feedback to their staff but send feedback on request only.This could cause frustration in the staff and in turn lead to low performance.The staff development department has taken note of this problem and has asked the administration to put it in their coming year strategy plan.We think this is very important; according to goalsetting theory, "feedback is necessary for effective goal achievement; it contains information and it is also motivational".

Safety environment
The following diagrams represent the lack of a safe environment in Al Buraimi hospital.According to Maslow's hierarchy of needs, safety needs are second from the bottom.This means these needs are very important and should be satisfied well in order to motivate medical professional staff.However, 70% of staff believe that the administration does not take care of them (Figure 6).For example, all foreign medical professional staff (excluding Omani staff) keep their passports in the personnel section of the hospital subject to civil rules, and they follow a very inflexible procedure if they want their passports back.The care they are looking for includes Badi 527

House allowance motivator
As Figure 7 shows, 82% of staff are not satisfied with the house allowance at Al Buraimi hospital.Despite the expensive rental flats, the administration of the hospital does not respond to staff requesting them to increase the amount of house allowance.This may be the main reason for them resigning, as sometimes the staff have to pay more to rent a nice flat from their basic salary.This serious problem affects the loyalty of staff and increases the likelihood of them resigning and moving to look for a good house allowance somewhere else.

Environment scanning
Naturally, any person wants to provide a good environment for his or her kids, and it is a big matter if you do not trust the place that you are in to provide enjoyment for your kids.According to the survey results, 82% of medical professional staff feel that their kids are not  happy in Al Buraimi (Figure 8).The reason for this feeling is because there are not many gardens and green parks in Al Buraimi.Also, 79% of medical professional staff are not satisfied about the education services in Al Buraimi city (Figure 9).They have to look for private schools in Al Ain city, which has high standards of education.This process of course costs them more money, and brings them back to the start, that is, the salary is not enough.
Because of this situation, staff will strive to get UAE visiting visas for them and their kids.As the diagram shows, 92% of staff consider the UAE visiting visa to be very important for them (Figure 10); and when they get it and notice the large differences between the services in Al Buraimi and Al Ain they start to look for any chance to work in Al Ain City, and 100% of them would prefer to work there.A very big number -around 66% -of medical professional staff spend most of their time in Al Ain city rather than Al Buraimi City because they find there what they need for them and for their kids.For example, there are no KFC restaurants, hotels, hypermarkets, green parks or cinemas in Al Buraimi, which are all available in Al Ain city.We think these are the main reasons leading the medical professional staff of Al Buraimi hospital to resign and go to work in Al Ain hospital (Figures 11 and  12).
In conclusion, motivational factors are very important for any organization, and because of the intertwining nature of motivational processes it is difficult to measure the motivation.So we cannot measure motivation directly, instead we manipulate some stimulus condition and then measure some behaviour in the form of a response.Based on our findings from the online interviews and employee motivations survey, we found that there are many serious reasons for the resignations of the medical professional staff of Al Buraimi hospital.These findings can be summarized as lack of motivation, so we have supported our report with some motivational theories, which have helped us to analyse our findings and come up with effective recommendations for the administration of the hospital in order to fill these motivational gaps.

RECOMMENDATIONS
Based on our results and findings, we have compiled some recommendations, which are proposed according to the inputs of our issue -the lack of motivation factorsand the outputs of motivational theories.It is strongly believed that administrators have to pay attention to these recommendations to help overcome motivational problems at Al Buraimi hospital.They are as follows: 1.The salaries of medical professional staff should meet other Gulf nations standards.The Ministry of Health has to be aware of the variance in salaries from country to another.The problem of variance of salary may expand to other places in Oman.This issue is discussed within Herzberg's theory, and the Ministry of Health should apply this theory to overcome this problem.2.Medical professional staff should participate in the organization's goal-setting plan.The administration of the hospital has to make its staff feel that they are part of the team in the hospital.According to Herzberg's theory, we can list this point under intrinsic rewards, which involve feelings of satisfaction; so when they participate in the goal-setting plan they will be satisfied somewhat.3.Feedback on performance should be sent regularly.The staff development section of the hospital has to pay close attention to this point to avoid frustration and low performance in staff.Goal-setting theory is emphasized at this point as it is necessary for effective goal achievement and is considered one of its four main propositions.4.The top management should provide a safe working environment.The need for a safe environment is very important for medical professional staff.Maslow's theory lists it as the second need in his hierarchy.5.There should be some flexibility in dealing with the medical professional staff; the administration of the hospital should increase the number of personnel staff to ensure a speedy response in any process related to them.6.The structure of the house allowance should be redeveloped, taking into consideration the high increase   in rental costs; alternatively, the hospital could provide internal accommodation for the staff as a short-term solution.7. A clear job description and simple explanation of tasks and targets would help increase job satisfaction and the hospital administration should develop this policy.8.The Ministry of Health should provide a good working environment for the staff, including personal fulfilment, and develop the staff potential.9. Affiliation needs are very important, according to Maslow's theory, because they are concerned with affection, relationships and love; medical professional staff should be supported in terms of their family stability through the provision of good conditions for their families.For example, the hospital could create some gardens with small play areas for kids inside the internal accommodation.10.The major concern of medical professional staff is the low level of education services for their kids; this problem makes them work under tension, and most of the time they eventually give up and resign.The Ministry of Health, along with the Ministry of Education, should aim to gather information and find the best solution to this problem, by increasing the standard of the private schools.11.Because there is a lack of civil services in Al Buraimi itself, such as restaurants and hypermarkets, the top management of the hospital should develop alternative procedures to decrease the effects of this problem until it is solved, for example, by increasing salaries or recognizing and rewarding high performers.Also facilitating the procedures for the staff to get UAE visiting visas could be an alternative solution to cover the gap in services in Al Buraimi city.

Figure 1 .
Figure 1.Salary as a very important motivation factor.

Figure 3 .
Figure 3. Lack of effect on the autonomy of making decision.

Figure 4 .
Figure 4. Chance to participate in goals setting plan.

Figure 8 .
Figure 8. Staff kids are happy in Al Burieme City.

Figure 9 .
Figure 9. Education services based on high standard levels.

Figure 10 .
Figure 10.The importance of having UAE visiting visa.

Figure 11 .
Figure 11.The favourite place to work is Al Ain.

Figure 12 .
Figure 12.The favourite place to enjoy is Al Ain