Increasing staff motivation is one of the management priorities in any field of activity. In accordance with the objectives of the state program of the Republic of Kazakhstan «Densaulyk 2016-2019», special attention is paid to solving this problem by developing the mechanisms of motivation of health care workers. Nursing is part of the health care system, which has significant human resources and real potential to meet the needs of the population for high- quality and affordable health care. The work motivation of nurses is one of the important areas of personnel policy of any medical organization. Despite the fact that work motivation is widely studied by nurses in other countries, unfortunately, a limited number of studies on this topic have been conducted in Kazakhstan. In order to study the factors affecting the work motivation of nurses in the database CHINAHL was conducted a review of international literature published from 2010 to 2017 in scientific journals.
Introduction. To date, Nursing in Kazakhstan has been undergoing a stage of reform. According to the «Comprehensive plan for the development of nursing in the Republic of Kazakhstan until 2020» the system of nursing in the Republic of Kazakhstan is gradually moving to the international level through introducing modern approaches to the functioning of medical organizations by introducing nursing organizational structures and innovative nursing technologies, and by developing evidence-based nursing practice. There will be redistribution of functional responsibilities between doctors and nurses of different levels of education from the vocational to the doctoral level. Gradually, nurses will be released from non-core functions they currently practice in order to expand their job description with increasing complexity and responsibility to care for patients. An adequate nursing care system that meets international requirements is being introduced. This should increase the motivation of nurses to improve professionalism and personal development, as well as reduce the turnover of nursing staff .
Increasing staff motivation is one of the priority tasks of management in any field of activity. Of particular importance is the solution of this problem in the healthcare sphere in connection with the tasks set in the State Program of the Republic of Kazakhstan «Densaulyk 2016-2019» . Nursing is part of the health care system that has significant human resources and real potential to meet the needs of the population for high-quality and affordable health care. Nurses directly affect the quality and safety of medical care . However, they become vulnerable to stress and reduced work motivation, which increases the risk of lowered working capacity and termination of work. Therefore, the work motivation of nurses is one of the most important directions of personnel policy of any medical organization. Despite the fact that work motivation has been widely studied by nurses in other countries , unfortunately a limited number of studies on this topic have been conducted in Kazakhstan.
Material and methods. Review of the international literature was conducted in order to study the factors that influence the work motivation of nurses. The CINAHL database was used. The search terms / keywords and combinations of terms that were used were as follows: nurse and motivation, nurse and job satisfaction. The search was limited to fulltext articles in English published in academic journals between the years 2010 and 2017.
Results and discussion. Work Motivation and related concepts. The search, development and retention of nurses are the prevailing global problems of nursing service management. Among all medical workers, nurses constitute the largest group of caregivers. They also have close daily personal contact with patients and their relatives. Sometimes, they experience stress and reduced motivation at work, which can lead to a risk of low productivity, thereby reducing the quality of services provided, and can in turn lead to dismissal from work. This increases the importance of motivating nurses to keep them in the workplace, and of the requirement for good management skills in performance management. Most studies of nursing work motivation point to several individual and organizational background factors that can be useful in studying nursing work motivation [4, 5]. In addition, some studies [6, 7] suggest that different aspects of work motivation should also be measured in order to better understand the behavior of nurses' work. Despite the long-term development of the theory of work motivation, researchers still face difficulties due to lack of reliable, accurate, and convenient key elements of motivation. Many researchers [4, 8] consider motivation as a phenomenon that changes only in its quantity, and are concentrated mainly on the intrinsic work motivation and its reinforcing factors. Although intrinsic work motivation is described as a natural and spontaneous propensity of a person, not all people have only intrinsic motivation.
Motivation is a complex and multidimensional concept. Grafham and other researchers have described motivation as a psychological process that gives direction to behavior . In turn, Be'gat and his colleagues described motivation as an internal drive that is present to meet unmet needs . Furthermore, McLean and Anema  described motivation as a will to achieve. Motivation also has a central role for the management of personnel in health care institutions. Researchers Bodur and İnfal studied the sources of nursing motivation and the related factors. Based on self-evaluation, internal motivation was recognized as the most important source of motivation for nurses .
Motivational factors of work give positive feelings and work as organizational pillars, increasing the productivity of employees. In addition, motivational factors increase the level of job satisfaction and help focus on the work itself .
Some researchers  have considered these motivational factors. They argue that there are internal and external factors of motivation. According to Iranmanesh and his colleagues, internal factors include a sense of participation, interesting work, and a sense of satisfaction from a well-done work, whereas external factors include work safety, good wages and good working conditions .
Other concepts associated with work motivation. Work satisfaction is defined as the degree of enjoyment of work. If people are stimulated, they will be more satisfied with the work. Job satisfaction is also closely related to the life satisfaction and these two concepts have an impact on the physical and mental health of people . Two-factor theories argue that there are certain factors in the workplace that cause job satisfaction, while a separate set of factors cause dissatisfaction . Dissatisfaction with work is caused by factors such as poor control, poor working conditions, unpleasant colleagues, low wages, poor management, and low labor safety .
To quote Herzberg and his colleagues ¨Job satisfaction and job dissatisfaction are not the obverse of each other... The opposite of job satisfaction would not be job dissatisfaction, but rather would be no job satisfaction. Similarly, the opposite of job dissatisfaction is no job dissatisfaction, not satisfaction with one's job” . In addition, Herzberg and other researchers presented factors that will improve job satisfaction such as achievement, recognition, responsibility, career growth, and job character. They classify these factors as motivators of job satisfaction. Satisfaction with work is a factor that occupies an important place in a person's life .
Satisfaction from work and harmony in the workplace are needed to make employees feel happy. Employee satisfaction affects the quality of health care. Motivators such as recognition and achievements in work make the work process more productive and creative.
Dissatisfaction with work often prevails over satisfaction in various health care institutions, both public and private . This dissatisfaction leads to low productivity, that is, to low quality of nursing care. In order to prevent this, we need to understand the concept of motivation and satisfaction. Motivation is formed from within, that is, from the individual needs of the employee, and satisfaction comes from the completion of a certain process.
The recruitment and retention of nurses is a constant job satisfaction related problem. The job satisfaction of nurses is closely related to working conditions and organizational environment .
Factors affecting to nurses work motivation. The satisfaction of nurses is a complex variable that affects the recruitment and retention of staff in all sectors of health. To be more precise, job satisfaction affects the quality of life of an employee, which ultimately can affect the care and treatment of patients . Factors that affect nursing job satisfaction may vary because nurses have different functions, service areas, levels of responsibility, accountability, and educational preparation. Therefore, it is important to identify various factors that can improve the level of job satisfaction, thereby improving the status of nurses, retaining staff, maximizing the quality of care.
The high motivation of nurses contributes to job satisfaction and consequently prevents staff turnover and increases the effectiveness of nursing care .
There are some peculiarities in nursing, as it is predominantly a female profession . Along with the overload of work in the workplace, employees have domestic chores and the upbringing of their children, which leads to the accumulation of functions. In connection with the characteristics of nurses' work, dissatisfaction among nurses begins with the working environment, because the very nature of the medical institution and the activities performed in this environment are often harmful to health. In addition, low wages, lack of social recognition, and conflicted relations leave their mark. This discontent has a negative impact on the professional as well as personal life and on the quality of medical care .
Nurses who are satisfied with their work are more productive and eager to work, while dissatisfied nurses have absenteeism and displeasure and, therefore, a large turnover among them. Satisfaction with work is the main element for retaining workers in any organization .
There is a shortage of nurses on all continents; this is due to two main factors: high staff turnover and a decrease in the proportion of nurses who remain in the profession. As a result, nurses who remain in the profession have increased workloads . The main factors that affect dismissal are health problems, stress in the workplace, and dissatisfaction with work.
Nurses who are satisfied with their work are more productive, and therefore there is more chance that they will remain at work . The management of medical institutions uses various incentives to retain experienced staff. Encouraging nurses improves staff morale.
The results of the research from Iran showed that external motivational factors are more important than internal factors in creating work motivation among nursing respondents. The study revealed that in the Iranian health care system, nurses have almost the lowest level of wages. Therefore, an external motive, like wages, is an important factor for work motivation . In contrast, when studying the labor motivation of Estonian nurses, it was revealed that nurses were moderately externally motivated and strongly internally motivated. Age and length of service of nurses positively correlated with introjected regulation .
65 nurses and 15 doctors took part in a study to identify the level of staff satisfaction of one of the medical centers in Bursa. When comparing the levels of work satisfaction of nurses and doctors, a significant difference was found only in work motivation. Compared with the doctors, the motivation of nurses was significantly higher. However, the comparison of motivation between men and women did not show any significant differences. The study also found that the level of nursing education does not affect job satisfaction. Compared with female doctors, nurses were more satisfied with career opportunities. However, it was found that low wages cause discontent in the work of nurses and doctors. .
A study conducted by Faris and other researchers described the level of job satisfaction and barriers in work of advanced practice nurses (APN) working in the Veterans Health Administration (USA). Overall, the study showed that advanced practice nurses are minimally satisfied with their work. They were the most satisfied with their autonomy and the least satisfied with the opportunities for professional growth and the level of partnership and collegiality in practice .
254 practicing nurses participated in a study by De Milt and colleagues on job satisfaction and the intention to leave their current position or nursing profession. 27% of respondents indicated their intention to leave their current position and 5.5% indicated the intention to leave the nursing profession altogether. There are significant differences in job satisfaction between nurses with the intention to leave their current position and those with the intention to stay. According to the researchers, the satisfying factors related to the preservation of the workplace included their primary responsibility for care and the feedback from patients and their families. Furthermore, studies have shown a direct link between employee satisfaction and patient satisfaction .
The level of job satisfaction among nurses in public and private clinics in Andhra Pradesh was compared in a study conducted by Indian researchers. The study revealed that the level of job satisfaction is greater for public nurses than for private nurses. Compared with the nurses from private hospitals, the nurses from public hospitals were significantly more satisfied with their wages and various incentives .
A study by Telles showed that nurses who have a balanced and financially secure life, a family, children, a home, a higher hourly wage, and a higher income from other sources are more satisfied with their work .
A study by Haso and colleagues found out that motivated nurses are more likely to apply their knowledge and skills in the workplace, and indicate that the effective use of the skills of well-motivated nurses contributes to the creation of good nursing care . The motivation of health care personnel can influence the creation of conditions for the provision of health services. However, in developing countries and countries with mid-range income, low staff motivation and inadequate human resources for health care are factors that lead to the abuse of health systems and health services .
According to the World Health Organization (WHO), there is currently a global shortage of human resources in the field of health care and in many countries, specifically a shortage of nursing staff. Nurses are critical to the delivery of health services and they are constantly responsive to people's needs. Therefore, nurses should be motivated to provide high-quality medical care for the population. To do this, it is necessary to create favorable conditions for work, such as provide the necessary equipment, resources, and compensation to attract and retain nurses in the workplace .
In a study by Seidakova and colleagues in the Commonwealth of Independent States, it was found that in most cases nurses, without even noticing it, limit themselves to previously acquired knowledge and do not engage in their own development, being tempted by deceptive calmness, stability, and security. This makes their work monotonous, boring, and hopeless, which can cause fatigue and overwork. According to the researchers, in order to fully harness the potential of the nurses, it is necessary to create conditions for work on their own site, monitor their activities, and systematically improve the level of education. Specifically, there is a need to educate nurses on their emotional attitude towards themselves, their profession, and therefore towards their patients .
Discussion. In this literature review, publications in the field of work motivation of nurses from different countries were studied. The theoretical aspects of work motivation have been developing for a long time, but despite this, many researchers still have difficulties because there are no accurate and reliable elements of motivation defined. Many researchers noted that the decrease in work motivation leads to low efficiency and to a decrease in the quality of services provided. This can also lead to increased staff turnover [4, 5]. The researchers clearly noted that motivation plays an important role in the management of personnel in medical institutions .
The researchers examined the concepts related to work motivation, such as motivational factors and job satisfaction and dissatisfaction [13, 15, 16]. According to Herzberg, job satisfaction and job dissatisfaction are not opposites of each other . Internal and external motivational factors causing job satisfaction as well as external factors causing job dissatisfaction were studied. In general, it was noted that the efficiency of nursing care provided by highly motivated nurses was increased .
It was also noted that nursing is mainly a female profession. Therefore, along with their work, nurses have other duties such as household chores and raising children. In addition, low motivational factors at work, such as low wages, lack of social recognition, and conflicted relations in the team can negatively affect the professional and personal life of the nurse .
Globally, there is a shortage of nursing staff, which is mainly due to the high turnover. As a result, much of the burden falls on the shoulders of the remaining nurses. The researchers noted that the reasons for the resigning of nurses are associated with stress and dissatisfaction with working conditions . To avoid this, it is necessary to encourage and improve the morale of nurses .
According to one of the studies, the level of education does not affect job satisfaction. Actually, in comparison with doctors, nurses were more satisfied with their work and career opportunities.
Furthermore, the researchers noted that the motivation of nurses was much higher when compared with doctors . However, nurses of advanced practice working in the public health veterans administration (USA) reported being minimally satisfied with their work; the most satisfied they were with their autonomy and the least satisfied with professional growth opportunities .
These studies have shown that external motivating factors are the priority, while internal work motivation also plays an important role. In addition, it can be noted that the work motivation of nurses depends mainly on the support of the administration of a certain medical institution and the health care system of the country as a whole.
Conclusion. The literature review showed that the study of factors that increase the motivation of nurses is a topical issue in many countries. Also, according to WHO, the nursing workforce is crucial in providing high-quality patient care, but currently the motivation and retention of the nurses is a big challenge . In this regard, based on international experience, it is necessary to study the factors that increase the motivation of nurses in Kazakhstan with the use of appropriate and valid tools.
- 1.«Комплексный план развития сестринского дела в Республике Казахстан до 2020 года». 2014.
- 2.Государственная программа развития здравоохранения Республики Казахстан «Денсаулық» на 2016-2019 годы. 2016.
- 3.Иванченко Н.Н., Павлова А.П., Мартыкенова Д.С., Юсупова Н.С., Касиев Б.С. Анализ реформирования сестринского дела в Республике Казахстан. Вестник КазНМУ. 2014; 2(4):135-137.
- Toode K., Routasalo P., Suominen T. Work motivation of nurses: a literature review. International Journal of Nursing Studies. 2011; 48: 246 – 57.
- Toode K., Routasalo P., Helminen M., Suominen T. Hospital nurses' work motivation. Scandinavian Journal of Caring Sciences. 2015; 29: 248 – 257.
- Meyer J., Becker T., Vandenberghe C. Employee commitment and motivation: A conceptual analysis and integrative model. Journal of Applied Psychology. 2004; 89: 991-1007.
- Altindis S. Job motivation and organizational commitment among the health professionals: a questionnaire survey. African Journal of Business Management. 2011; 5: 86018609.
- Ryan R.M., Deci E.L. Intrinsic and extrinsic motivations: classic defini-tions and new directions. Contemporary Educational Psychology. 2000; 25: 54 –67.
- Grafham E., Matheson C., Bond C.M. Specialist drug misuse nurse's motivation, clinical decision-making and professional communication: An exploratory study. Journal Psychiatric Mental Health Nursing. 2004; 11: 690-697.
- Be´gat I., Ellefsen B., Severinsson E. Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being – a Norwegian study. Journal Nursing Management. 2005; 13: 221-230.
- McLean T., Anema M. Reduce the nursing shortage: Help inactive nurses return to work. Journal of Continuing Education in Nursing. 2004; 35: 211-215.
- Bodur S., İnfal S. Nurses' working motivation sources and related factors: A questionnaire survey. International Journal of Human Sciences. 2015; 12(1): 70-79.
- 13.Oladotun K.J., Цztьren A. Motivational factors of hospital employees: evidence from north Cyprus. Interdisciplinary Journal of Contemporary Research in Business. 2013; 4(12): 106-123.
- 14.Bakay A., Huang J. Conceptual Model of Motivational Antecedents of Job Outcomes and how Organizational Culture Moderates. Social Science Research Network (SSRN) Electronic Journal. 2010; 12: 1-12.
- 15.Iranmanesh S., Fuladvandi M., Ameri G., Bahrampoor A. Iranian Nurses, Organizational Commitment and Job Motivation, 2014; 4(2): 189-194.
- Akansel N., Цzkaya G., Ercan I., Alper Z. Job Satisfactions of Nurses and Physicians Working in the Same Health Care Facility in Turkey, International Journal of Caring Sciences. 2011; 4(3): 133-143.
- Herzberg F., Mausner B., Snyderman B. The Motivation to Work. New Brunswick, New Jersey. 1993.
- Faris J., Douglas M., Maples D., Berg L., Thrailkill A. Job satisfaction of advanced practice nurses in the Veterans Health Administration. Journal of the American Academy of Nurse Practitioners. 2010; 22: 35-44.
- Lu H., Barriball K. L., Zhang X., While A.E. Job satisfaction among hospital nurses revisited: A systematic review. International Journal of Nursing Studies. 2012; 49: 10-17.
- De Milt D., Fitzpatrick J., Sister Rita McNulty. Nurse practitioners' job satisfaction and the intention to leave the current positions, the nursing profession, and the nurse practitioner as a direct care provider. Journal of the American Academy of Nurse Practitioners. 2011; 23: 42-50.
- 21.Somense C.B., Duran E.C.M. Satisfaction/motivation of Nurses: integrative review. Journal of Nursing. 2014; 8(7): 3172-3181.
- 22.Gupta M., Reddy S., Prabha C., Chandna M. A Comparative Study on Level of Job Satisfaction among Nurses in Government and Private Hospitals of Andhra Pradesh, IndiaInternational Journal of Nursing Education. 2014; 6(1): 183-188.
- 23.Sriratanaprapat J., Songwathana P. Nurses' Job Satisfaction within the Context of Asian Cultures: A Concept Analysis. Pacific Rim International Journal of Nursing Research. 2011; 15(1): 57-73.
- Tellez M. Work Satisfaction Among California Registered Nurses: A Longitudinal Comparative Analysis. NURSING ECONOMIC$. 2012; 30(2): 73-81.
- Haso T.K., Seid S.S., Ibro S.A., Abebe F. Factors Affecting Motivation of Primary Health Care Workers in West Arsi Zone, Oromia Region, South East of Ethiopia. Advanced Practices in Nursing. 2018; 3(1).
- Weldegebriel Z., Ejigu Y., Weldegebreal F., Woldie M. Motivation of health workers and associated factors in public hospitals of West Amhara, Northwest Ethiopia. Patient Preference and Adherence. 2016; 10: 159-169.
- World Health Organization. Global strategic directions for strengthening nursing and midwifery 2016-2020. 2016.
- Сейдакова Г.С., Сабирова А.Т., Каландарова Г.К., Бегалиева Р.М. Принципы условий труда медицинских сестер. Молодой ученый. 2015; 11: 710-713.