The Role of Culture in Motivating the Workforce in the Healthcare Environment

C. Carolina Teran

Different authorities in the field agree that "organizational commitment research has been primarily associated with U.S. organizations yielding outcomes including increased job satisfaction (Bateman & Strasser, 1984), increased job performance (Cohen, 1992), leadership (Morris & Sherman, 1981), and decreased burnout (Wright & Bonett, 1997), as well as personal characteristics such as increased well-being (Mowday et al., 1982)" (as cited in Madlock, 2012 ). This paper will discuss Hofstede's cultural dimensions observed in Mexicans and Americans, as factors that define strategies to better motivate employees. It also will include an Appendix with a reasoning of the strengths of each dimension that are more commonly seen in the United States.

Nursing Administration: Scope and Standards of Practice

The healthcare industry is crossing through a tough era and employees demand more and more every day. According to American Nurses Association (ANA) (2009), the problems faced by the industry include: a workforce shortage and aging, different experience and education, rising costs of healthcare, natural and man-made disasters and environmental damage from medical waste. Even more, the inevitable crisis Mexico is going through economically and on safety grounds have pushed many to look into different paths, many of them migrating to U.S. and some of them entering the healthcare industry which mandates leaders to be multicultural educated.

As servers in the healthcare system, we must adhere to the Standards of Practice for Nurse Administrators. ANA has defined a transformational leader as one who "foster open communication horizontally and vertically, provide inspiration and enthusiasm, and create harmony among staff. They seek to improve communication, staff satisfaction, and output" (as cited in ANA, 2009). ANA also explains the concept of leadership as a process of developing an organizational structure, where inclusive decision making can arise, and where creative and supportive personnel policies and models of care exist.

"Motivation is still considered to be a key element within organizational behavior, and a motivated workforce continues to be regarded as essential for the competitiveness of organizations" (Navarro, Yepes, Ayala, de Quijano, 2011). As result, transformational leaders must strive to create a good work environment, where objectives are achieved effectively and efficiently and at the same time, personnel enrich their lives through transferal skills and abilities. Ensuring staff satisfaction is easier said than done, the ANA Bill of Rights for Registered Nurses (2001) mentions "nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional responsibilities" (ANA, 2009).

Finally, ANA (2009) explains that mentoring occurs only when we embrace cultural diversity and accept nurses' rights equally, regardless of their background or any other factor that can be attributed to unfair discrimination.

Evidence in the Literature: Motivation Theories

In 1998 Quijano and Navarro proposed an integrated model of work motivation that integrates contributions from different theorists, for instance "classical theory such as needs (Alderfer, 1972; Herzberg, Mausner, & Snyderman, 1959; Maslow, 1954; McClelland, 1961), the concept of instrumentality from VIE theory (Vroom, 1964), self-efficacy from social cognitive theory (Bandura, 1986), perceived equity, a concept used in theories of organizational justice (Adams, 1965), and critical psychological states from the job characteristics model (Hackman & Oldham, 1976)" (Navarro, et. al. 2011).This model is based on the hypothesis that individuals have a set of specific needs which, in the case of workers, drive them to behave in certain ways so as to satisfy them. "The model considers a set of 10 different needs: 1) pay; 2) health and physical cover; 3) stability at work; 4) relationships with co-workers; 5) support from managers; 6) recognition for work well done; 7) improvement in retribution; ? promotion; 9) applying knowledge and skills; and 10) professional development" (Navarro et. al., 2011). Consequently, understanding the diversity in the workforce and the needs of each employee would lead to a more motivated workforce.

Maslow's Hierarchy of Needs (Golnaz & Clarke, 2011) also helps us understand motivation. It explains that once physiological, safety, belonging and self-esteem needs have been met we can move to the final level, self-actualization. Our purpose as leaders is to create a better environment at our work environment so that employees can meet their basic needs and can work on those skills that will put them at the top of society's expectations. At the self-actualization stage employees can reach their potential and continue to work on it. Their perspective to life changes; Critical thinking, creativity, spontaneity, problem solving, and judgment are skills that can be achieved in this level.

Motivated employees work harder, produce higher quality and greater quantities of work, are more likely to engage in organizational citizenship behaviors, and are less likely to leave the organization in search of more fulfilling opportunities. Competition by companies to attract the most talented individuals has given employees the power to demand more than just a reasonable wage or salary, and there is evidence that companies are starting to listen (Golnaz & Clarke, 2011).

This paper focuses on level of education and income and the Hofstede cultural dimensions in the Mexican and American culture as instruments to determine what employees are looking for.

Level of Education

During the past several years, Mexico has made significant advances in literacy and to the provision of public education however, these advances have not been enough. Mexican law mandates universal preschool, primary, and secondary education, in total eleven years of education are compulsory. According to Mexicanos Primero (Mexicans First) only 45% of Mexicans finish secondary school. By contrast, about 75% of U.S. students graduate from high school on time with a regular diploma, according to the U.S. Department of Education (as cited in Rama, 2011).

Income Level

Mexico is a middle-income country with a developing market economy that is closely linked to the superior economy of the United States. Mexico has made advancement in reducing poverty since the 1990s, performing above the Latin American average. However, nearly half the population continues to live in poverty levels and about 15% of the total population exists in extreme poverty (Library of Congress, 2008), pushing many to come to the US for better opportunities and a better way of living.

Hofstede's Cultural Dimensions

A culture reflects attitudes, beliefs, perceptions and values that persons share in relation to something else. Hofstede has acknowledged four cultural dimensions which include:

Individualism-collectivism

Individualism-collectivism cultural dimension refers to the individuals' choice of working as a group or individually to deal with a situation. The United States, the United Kingdom, and Canada tend to emphasize their individual needs, concerns, and interests over those of their group or organization (as cited in Altaf, 2011).

Refer to Appendix 'A' for more information

Power distance

Power distance is defined as the degree to which differences in power and status are accepted in a culture. White (1953) distinguished three different leadership styles: authoritarian, democratic, and laissez-faire. The authoritarian style could be described as a high power distance. "It is directive and their subordinates were productive, but generally only so long as the leaders were in the room or otherwise keeping close watch, and all policy is decided by the leader". On a low power distance two styles of leadership are common Democratic leadership and Laissez-faire. Democratic leaders empower their followers. Laissez-faire leaders are as nondirective as possible much of the time, leaving it to the employees to figure out what to do (as cited in Yang, Wang, Chang, Guo & Huang, 2009). The US has a low power distance culture, employees and employers act in conjunction towards a goal (as cited in Altaf, 2011). In contrast in a hierarchical society; employees obey orders and hesitate to voice their opinions, for example a study done in Taiwan revealed that the lowest agreement was on the item, "When I made suggestions about safety to my executive, the suggestions were adopted easily and implemented in the work place" (Yang et. al., 2009).

Refer to Appendix 'B' for more information

Uncertainty Avoidance

Societies with high in uncertainty avoidance tend to prefer rules and to operate in predictable situations (as cited in Altaf, 2011). The National Health Service (NHS) in Britain (2000) indicated that at least 400 patients died or were seriously injured in disastrous events involving medical devices. This report emphasized that "hospitals should reduce faulty systems and process errors that lead people making mistakes" (as cited in Yang et.al. 2009).

Refer to Appendix 'C' for more information

Masculinity-femininity

The masculinity-femininity dimension of a culture refers to the degree to which values related with stereotypes of masculinity (such aggressiveness and dominance) and femininity (such as compassion, empathy, and emotional openness) is accentuated. High masculinity cultures such as Japan, Germany, Mexico and the United States tend to have more gender-differentiated occupational structures and there is a stronger emphasis on achievement, growth, and challenge in jobs (as cited in Altaf, 2011).

The Institute of Medicine has suggested creating a non-punitive culture as "the first step in implementing a safety healthcare system and accident investigation system" (as cited in Yang et. al., 2009).

Refer to Appendix 'D' for more information

Motivation Strategies

Through exploring the different cultural dimensions we can create a plan to better motivate our employees. For example, if my employee is from an individualistic culture then as manager we can plan to praise him in front of other people, nonetheless if my employee comes from a collectivistic country then that might be counter-productive, the employee could feel he is being separated from his team or recognized unfairly.

American Culture

American employees tend to value individualism, accept risk, work closely with superiors and enjoy achievement and growth. American workers would benefit from exercising power over work assignments and work conditions. Zohar (2003) showed that a "leader encouraging workers participation and system implementation could enhance employees' desires to improve the safety climate" in the healthcare environment (as cited in Yang et.al, 2009). Americans benefit from a work environment that allows them to make decisions and solve problems, where they can show initiative and creativity. Superiors should maintain a close relationship with the employees, it is vital that superiors show respect and value to their subordinates. American employees value a two way communication that is informal, honest and collaborative where information flows smoothly from one level to another without fear of retaliation. These employees are willing to accept change and work under new, unexpected conditions with few or no rules. Most important, individuals value personal and professional growth, so it is expected that the work place allows for promotion, with better salary and benefits and space to acquire new skills.

Mexican Culture

Mexican employees need rules, avoid risk, respect the authority and value achievement and growth. Mexican employees are hard workers and very responsible and prefer a secure job with a lower pay than a risky job with higher earnings.

Mottet and Richmond (1998) identified various strategies to boost communication and loyalty among Mexican workers, for example: personal recognition (e.g., calling a coworker by his or her name), inclusiveness (e.g., inviting someone to participate in organizational activities), openness (e.g., informing a colleague of organizational plans), and compliments (e.g., telling someone when a task was done well) (as cited in Madlock, 2012).

The Mexican culture is perceived as a collectivist country; however, it is important to differentiate that Mexicans value family over any organizational group. "The Mexican worker worries about how work is going to impact family time in pursuit of higher productivity. Thus, the Mexican worker may frown upon the idea of working longer hours or working during undeclared religious holidays" (Najera, 2008). In a conflict situation, members of the collectivistic cultures are likely to use avoidance, intermediaries, or other face-saving techniques rather than facing the problem or the authority. It is not uncommon to see this culture displaying traditional "familistic" values such as male dominance and respect for the elderly and those in high power positions.

Teagarden et al., (1992), Stephens and Greer (1995), and de Forest (1994) mention not only the significance in the workers showing respect towards the supervisor but the supervisor also returning the respect to the worker. In return for their dedication to their supervisors, the workers expect a certain level of emotional support and trust (as cited in Najera, 2008).

In Mexican culture, familiarity and security are two values that are strongly treasured by the culture, as well as the attitude of living the moment. "Mexicans seek present satisfaction and prefer "known" results to "unknown" future outcomes...While the US culture view work as a reward based on their work production, the Mexican culture see work as necessary to live in order to enjoy worldly pleasures with family and friends" (as cited in Najera, 2008).

Mexican American Culture

Another very important aspect a manager must consider is that a lot of Mexicans come to the United States in search of a better way of living, not only economically but also in a personal level. Therefore, it is important to acknowledge Mexican Americans as a new culture. "Acculturation is a multidimensional process involving changes in attitudes, behavior, awareness, loyalty, and values" (as cited in Coltrane, Parke & Adams, 2004). Latinos now constitute the largest "minority" group in the United States, and approximately two-thirds of this group is of Mexican descent more commonly referred to as Mexican American. Mexican American families have low social mobility and experience discreet change in family income across generations as compared to other cultures in the US. "Latinos, especially Mexican Americans, tend to be employed in the service sector and occupy jobs with low pay, limited benefits, few opportunities for advancement, and periodic instability." In general, Latino groups speak Spanish predominantly, have lower education levels and lower occupational status, in addition Latino groups manifest high family solidarity and ethnic identity (as cited in Coltrane et. al., 2004).

Employees in the United States should be active participants in decision making and be betrothed in dynamic exchange of ideas and perspectives with the organization. Nevertheless, "power and status differences should not be diminished but acknowledged and emphasized as they are part of organizational life in Mexican organizations" (Madlock, 2012). In the healthcare environment, these employees can benefit if their superiors delegate some decision-making that would allow them to take action quickly and flexible to meet patients' needs. However, nurses cannot practice completely in isolation because; they are accountable to and dependent on specialists in their profession, and most important their culture will still be present and might affect their performance. Therefore, physicians' engagement is vital here; their expertise would permit that only quality service is provided. Even more, "successful implementation and dissemination of continuous quality improvement are linked to the involvement of physician leaders, hospital executives, and hospital boards" (Cowen et al., 2008).

The study realized by Navarro et. al. analyzed 145 employees of a Mexican hospital. The study revealed that Mexicans value both intrinsic needs and external needs. Participants motivated predominantly by intrinsic factors valued relationships with co-workers, support from managers, recognition for work well done, applying knowledge and skills, and professional development. In contrast, participants motivated predominantly by extrinsic factors valued pay, health and physical cover, stability at work, improvement in retribution, and promotion (Navarro et. a., 2011).

Limitations

A solid limitation to this paper is the continual change in cultural dimensions among countries and individuals. For example a study done by Rotondo, Carlson, Stepina & Nicholson (1997) revealed that there have been shifts in the cultural dimensions in different countries, specifically, the shift made by the United States from being a weak uncertainty avoidance country in Hofstede's study to being a strong uncertainty avoidance country in the present study. This change is attributed to the political, economic, and social changes the United States has endured over the past decades. Mexico's current efforts to restore its failing economy have pushed the country to accept bigger risks. Similarly, the recent study revealed that the Mexican culture as individualistic, the trend toward more economic development in Mexico supports the shift. Finally, the United States scored as a feminine country in this study. This result is consistent with changes in the work force, as more women have gained positions of power since Hofstede's data collection (Rotondo, Carlson, Stepina & Nicholson, 1997).

Conclusion

Motivational behavior significantly affects performance in the healthcare environment. Unsafely practices are most of the times a result of the organization's leaders inability to support and commit to their employees. A possible solution is to "increase cohesiveness and perception of the hospital's organization by building direct communication and providing more commitment and support to medical staff in order to initially handle medical disputes properly" (Yang et.al., 2009). Participative leadership style was the preeminent practice for cultivating safety culture and safety policy in organizations. Participation style leadership also led workers to accept accountability and ownership for safety (Yang et.al, 2009).

Multicultural education edifies a leader. It is a continuous learning process where we develop a better understanding of the values, attitudes, perceptions and ideas of the people we coexist. Multicultural education is a very valuable resource but not acknowledging as such has set a barrier in improving the human relationships between supervisors and employees.

Finally, this study intends to promote cultural awareness and respect of others as a mean to achieve organization's goals and growth.

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