INTRODUCTION
Despite the rise in demand for high-quality healthcare services for patients, there are limited resources that often pose a challenge to their sustainability (Pencheon, 2013). Resources and organisational model constraints may negatively impact the motivation of healthcare employees (Ilic et al., 2024). Therefore, working motivation in healthcare organisations, especially in nursing, has become increasingly important to address these challenges and meet the growing demands towards employees (Toode et al., 2011). It is crucial to analyse the factors that affect the motivation of nurses/technicians to provide top-notch healthcare services and ensure positive outcomes for patients (Galletta et al., 2016). Creating a work environment that relies on responsibility, honesty, and ethics while nurturing the staff's skills, knowledge, compassion, and creativity is vital to building a good organisation (Gavrić and Bavrka, 2020). The shortage and fluctuation of nurses/technicians represent a global challenge (Hayes et al., 2012), and working motivation is crucial for retaining staff in the healthcare sector (Ahlstedt et al., 2020).
Both tangible and intangible rewards can influence motivation at work. While tangible rewards can provide some level of satisfaction, intangible rewards are more effective in fulfilling higher needs, such as growth and self-actualisation (Ćulafić et al., 2021). These rewards include feedback on the quality of work, involvement in decision-making, and autonomy at work (Dessler, 2013). In green human resource management, intangible motivational techniques can also include green training and development to increase awareness of how the institution's activities and individuals can impact the environment. Additionally, rewarding employees for their green efforts through promotions or awards can be an effective motivational tool (Jaganjac et al., 2024). Since plenty of time is spent at the workplace, a pleasant atmosphere in the team and good communication are of great importance, and, therefore, the organisation needs to create efficient relations between the manager and the employees, among the employees, as well as between the employees and service users (Vasilev and Stefanova, 2021). Nurses/technicians are motivated when they know that their activities will lead to fulfilling their goals and expected awards with the precondition that the activities undertaken are also essential for the organisation. (Eminović et al., 2023). The system of motivation should be designed to satisfy both, the economic and the psychological needs of the employees and to encourage the employees to achieve organisational goals. (Lorincova et al., 2019).
Healthcare organisational models are evolving to keep up with economic, social, and demographic changes, and technological advancements. The increasing awareness of people on their rights to healthcare and treatment, and the ageing population, are also important factors to consider. The safety of patients and healthcare providers, and a patient-centred system are a top priority in healthcare (Ovčina et al., 2018). This paper analyses functional, team-based, and patient-centred models as the most used models at hospitals.
Hospitals are often organised on the functional principle and consist of independently controlled departments (Fioro et al., 2018). The functional model is also known as the task-based model. The work is divided into tasks performed by different medical workers, mostly mechanically and routinely (Huber, 2014). The approach to the patient is fragmented. The head nurse organises the staff so that all the workers on the shift take care of all the patients, and each worker performs the tasks assigned. This is a hierarchical model in which the head nurses perform the complex and managerial jobs, while the nurses/technicians perform basic tasks. This model can be efficient for healthcare institutions with limited resources since it requires fewer employees but, enables the specialisation of nurses who can focus on the tasks for which they are best trained and have expertise. From the motivational aspect, this model can cause reduced intangible motivation because of the routinisation and somewhat difficult interaction among the medical workers, thus negatively affecting teamwork spirit (Oldland et al., 2014; Parierra et al, 2021). In addition, using specific skills to perform the same tasks may lead to stagnation in other skills and knowledge development.
The team-based model promotes collaboration among nurses who work together to provide patient care. The model involves dividing nurses into teams, which are then coordinated and managed by leaders who maximise the competencies of each team member (Huber, 2014; Fawcet, 2021). This approach emphasises the importance of teamwork in providing holistic care to patients and improving the overall quality of healthcare. In the team-based model, team members are assigned clear roles to promote job satisfaction. Efficient teams working under this model are characterised by common goals, effective communication, measurable outcomes, and efficient leadership (Mitchell et al., 2012). Management is decentralised, which ensures support to new, less experienced nurses from the more experienced and competent professionals. This approach promotes knowledge and skills development through efficient work and enables the identification of training needs. This model deploys a greater number of nurses, compared to the functional model (Parriera et al., 2021).
The patient-centred model is a newer model that focuses on the healthcare user, unlike the task-focused functional model. Although there is a significant volume of theoretical managerial literature on this model, there are rare evaluations of the success of hospitals that have moved from a functional patient-centred model (Fiorio et al., 2018). This model can lead to improved patient care outcomes and increased patient satisfaction, as it recognises the need for individual patient care tailored to their specific needs. This multidisciplinary model acknowledges that patients may require support from various healthcare professionals to receive adequate care. This approach demands that healthcare workers possess excellent listening, communication and negotiation skills, and the ability to respond flexibly to individual patient needs (Coulter and Oldham, 2016). It requires support, training, good leadership and constructive cooperation within the interprofessional team (Vennedey et al., 2020).
The model can cause higher workloads and challenges for staff, especially in a bustling work environment. Research conducted by Gustavsson et al. (2023) has shown that transitioning to this model can lead to challenges in adapting to new professional roles, dealing with ambiguity in organisational structures, and shifting from a task-oriented to a patient-centred approach to care. According to the same source, improved job satisfaction is achieved when providing services according to this model by following ethical expectations, receiving recognition from patients and colleagues, improving teamwork, and strengthening motivation due to the acquisition of new skills.
Based on the theoretical assumptions about selected healthcare organisational models, the following hypothesis is developed:
H1: The healthcare organisational model impacts the intangible motivation of nurses/technicians.
1. RESEARCH METHODOLOGY
The study was conducted at Zenica Cantonal Hospital from November 15th to December 15th, 2023. The data were collected using a survey technique. A survey questionnaire that had closed-ended questions was created by the authors, based on a review of the literature. The statistical package SPSS 23.0 was used to process the data. Descriptive statistics, Pearson's correlation coefficient, and F-stat were used to analyse the data. Descriptive statistics included calculating the arithmetic mean, standard deviation, and standard i.e., marginal error for additional expression of population variability. Pearson's correlation coefficient was used to represent the relative dispersion of the data set with a significance level of α=0.05, and F-stat for the ratio of two variances. The reliability of the questionnaire was assessed using Cronbach's Alpha. Cronbach's Alpha coefficient is 0.897, indicating high internal consistency of the items. The result confirms that the statements in the questionnaire are well connected and consistent, and it can be expected to give stable and consistent results during repeated measurements.
The research plan involved examining nurses'/technicians' attitudes from the operational and managerial levels of Zenica Cantonal Hospital. A total of 100 respondents were surveyed, of which 20 were from the management level (head nurses/technicians of departments and services, and 80 were from the operational level (shift nurses, room nurses, instrumental nurses, ambulatory nurses). The respondents were asked to rate their answers on a Likert scale, ranging from 1 to 5.
2. RESULTS AND DISCUSSION
Of 100 respondents, 65% are women and 35% are men. The largest percentage of respondents is aged from 36 to 45 years (45%), followed by respondents aged 46 and over (27%). Respondents aged 25 to 35 make up 24% of respondents, and the smallest group of 4% is aged less than 25 years. Most respondents have 16 or more years of work experience (45%), 22% of respondents have from 11 to 15 years of work experience, 19% of respondents have 5 to 10 years of work experience, and 14% of respondents have less than 5 years of work experience. Respondents from the operational level made up 80% of the sample, and 20% from the managerial level. The results of the research on the organisational model of healthcare at Zenica Cantonal Hospital are shown in Table 1 and Table 2, whereby in Table 1, the first three statements present the attitudes of employees at the operational and managerial levels towards the organisational model, while in Table 2., the overall results for the operational and managerial levels are presented, to determine which model of healthcare is most represented at Zenica Cantonal Hospital. In Table 1, statements 4 to 11 examine the intangible motivation of nurses/technicians.
Table 1: Organisational model of healthcare and intangible motivation at Zenica Cantonal Hospital
Source: authors
Table 2: Organisational model of healthcare at Zenica Cantonal Hospital (managerial and operational level)
| Organisational model | Mean (N=100) | St.Dev |
|---|---|---|
| Functional | 4.15 | 1.085366 |
| Team-based | 3.94 | 1.034456 |
| Patient-centred | 4.06 | 1.104357 |
Source: authors
The results presented in Table 1 indicate no significant differences in the perception of the healthcare organisational model at Zenica Cantonal Hospital between the operational and managerial levels. According to Table 2, the functional model is mostly applied in the hospital per the respondents' views. In terms of intangible motivation (statements 4 to 10), it can be concluded that there are no significant differences between the operational and managerial levels. The P-values are greater than 0.05. As for statement 11, which refers to the impact of the organisational model on intangible motivation, there is no significant difference between the attitudes at the operational and managerial levels, where the P-value is greater than 0.05.
Both operational and managerial levels neither agree nor disagree that they are satisfied with the overall intangible motivational techniques, which indicates that it is necessary to reconsider intangible motivational techniques in use and analyse the human resource management system. Analysing given elements of intangible motivation, it can be concluded that the respondents mostly neither agree nor disagree with the fact that they are often engaged in interesting and challenging tasks, that they have autonomy when performing daily tasks, that they regularly receive feedback from superiors about the quality of their work, and that they participate in decision-making within the scope of work responsibilities. These elements of intangible motivation are given great importance in the literature (Bahtijarević-Šiber, 1999; Marušić, 2006; Rahimić, 2010; Scandura, 2019; Ross, 2021).
They belong to job design, which contains three essential components: job characteristics (interestingness, complexity, autonomy, job significance), job functions (work methods, responsibility, autonomy, job significance), and relationships (teamwork, feedback). From the employees' perspective, job characteristics, functions, and relationships significantly influence motivation, affecting organisational productivity (Jaganjac and Lukić-Nikolić, 2023, p. 221). Many studies in different settings have shown that these elements of intangible motivation have a significant impact on the retention of nurses/technicians and their job satisfaction (George et al., 2013), whether it is autonomy at work which is directly related to decision-making within the scope of work responsibilities (Dawson et al., 2014; Kramer and Schmalenberg, 2003), positive feedback from superiors (Kilpert and Jooste, 2002), or challenging and interesting tasks (Kohnen et al., 2023). Respondents least agree that they often have the opportunity to attend institution-organized training and that there is the possibility of being promoted at the operational level. Training is one of the most important aspects of health care improvement. Training on new ways of providing health care, new therapies and methods of application, symptomatology, and administrative tasks related to nursing positively impact the motivation and work of nurses/technicians, and this segment needs to be significantly improved. Training is one of the most important factors in the job satisfaction of nurses/technicians (Keith et al., 2021). Therefore, it is necessary to recognise the needs not only of the institution, but also of individuals for continuous training, and to develop training plans and strategies aligned with the specific needs of improving knowledge and skills, as well as the individual development goals (Tsirigoti et al., 2024). Given that the development of new knowledge and skills increases self-esteem and the possibility of being promoted, trainings are highly positioned on the scale of intangible motivation of nurses/technicians (Thu et al., 2015; Ankomah et al., 2016). The possibility of being promoted also depends on the organisational structure, the qualifications of the employees and institutional needs, so this limitation should be understood from the job systematisation perspective.
The motivation and satisfaction of nurses/technicians at all levels significantly impact the quality and efficiency of the institution's work. This, in turn, affects patient satisfaction and the overall quality of the healthcare system. Nurses'/technicians' motivation is crucial because their satisfaction affects patients, other healthcare workers and family members. The working environment should encourage knowledge and skills investment to employees, which they will implement in providing healthcare services. This leads to an increase in the quality of healthcare, the success of the institution, as well as personal satisfaction and self-esteem. Table 3 shows whether the healthcare organisational model impacts the intangible motivation of nurses/technicians.
Table 3: Impact of the organisational model on the intangible motivation of nurses/technicians
Source: authors, 2023
The patient-centred model has the strongest positive correlation with intangible motivation. The functional model, mostly applied in Zenica Cantonal Hospital, also positively correlates with intangible motivation. The team-based model shows the weakest correlation compared to the previous two models, although this model also impacts intangible motivation. This confirms the hypothesis that the organisational model impacts the intangible motivation of nurses/technicians. Healthcare models designed to optimise job satisfaction can help attract and retain staff. For the healthcare institution, it reduces the economic costs caused by frequent absences from work or fluctuations due to work dissatisfaction (Kramer and Schmalenberg, 2005). Satisfaction with intangible rewards positively correlates with healthcare workers' retention and loyalty (Bakker, 2011) and better communication with patients and colleagues (Shaw and Gupta, 2015). Research limitation comes from the fact that data was collected and analysed at the hospital level. Future research should involve more participants analysing the attitudes of nurses/technicians at the department level. Understanding the use of intangible motivational techniques at the department level would be beneficial for developing new plans, particularly for enhancing the knowledge of nurses/technicians by organising training programs tailored to the specific needs of the departments. This is important because respondents are least satisfied with this intangible motivation technique.
CONCLUSION
The healthcare organisational models impact the intangible motivation of nurses/ technicians. If organisational models do not adequately support intangible motivation, it can lead to higher employee turnover in the long run. Nurses/technicians at the operational and management levels are the least satisfied with the training opportunities provided by the hospital. Acquiring new knowledge is crucial for enhancing healthcare services and fulfilling the development needs of employees. There is a need to improve intangible motivation by effectively implementing intangible motivational techniques within studied organisational models. Prioritising the training of nurses/technicians is crucial, as other studies have also emphasised its high impact on intangible motivation. The functional model, with its narrow specialisation and reliance on specific skills for fulfilling the same tasks, can hinder the development of other skills and knowledge. The team model and the patient-centred model involve continual knowledge exchange, skill enhancement, and motivation reinforcement through learning new skills. Therefore, training is crucial for all healthcare organisational models. Acquiring new knowledge and skills paves the way for fulfilling other aspects of intangible motivation such as undertaking challenging tasks and jobs with more autonomy, and gaining the competencies for being promoted.