CareMiles : incentives for health care employees

CareMiles: Incentives For Health Care

Employees.

Supervisor: Prof. dr. Mirjam van Praag Amsterdam, July 2013

Abstract

The Dutch Nationale DenkTank has come up with an idea for the increasing costs in the health care, called ‘CareMiles’. Employees can earn points (called CareMiles) when they meet specific goals, and get a reward based on the number of CareMiles. The reward should increase the efficiency, because the employees are more motivated. Systems like this are more often used in the private sector. Multiple researches indicate that employees in the private sector are

extrinsically motivated, while public sector employees are intrinsically motivated. Based on these researches it can be questioned if the CareMiles system would work. With the survey held by Dutch health care organizations, it is confirmed that the system as suggested by the Nationale DenkTank will not increase employee motivation and it is expected that problems, like

freeriding, will occur. Hereby no difference between gender, age and work experience has been found.

Index

Appendix A: Enquête beloningssysteem in de zorg ... 24

Appendix B: Comments and suggestions of respondents ... 27

Introduction

It is important to keep employees motivated, but this is difficult in the health care because of the many changes. New technology, reorganizations and cost reductions are needed to meet the needs of the increasing population that needs health care. People are living longer and more people are ageing, with increasing costs as a consequence (Benson, 2003). Changes in strategic planning and efficiency are needed (White, 1998). To achieve this, the motivation of the employees and how they can be motivated needs to be understood.

In 2011 the Dutch Nationale DenkTank came up with 22 ideas to improve employee motivation in the health care sector. One of these ideas is the ‘CareMile’. Employees can earn points, called CareMiles, individually or with a team when they meet specific goals. These goals have a different theme every month in the categories productivity, quality of the health care, satisfaction of the patients and good fellowship. The employee or the team with the most

CareMiles at the end of the month gets a reward. The kind of reward should fit within the budget of the organization (Nationale DenkTank, 2011).

Incentives, like the CareMiles system or bonuses, are less common in the public sector than in the private sector. Most literature about incentives and employee motivation focus on the private sector. The public sector differs from the private sector at several aspects. One of them is their general goal, the private sector tries to make profits, the public sector focusses on serving social needs (Wright, 2001). This is also visible in the motivation of the employees. Employees in the private sector are most likely to be extrinsically motivated, while public sector employees are more likely to be intrinsically motivated. This should be taken in consideration when

thinking about incentives. Kreps (1997) states that giving extrinsic incentives, while the employees are intrinsically motivated can lower the effort of the employee. Therefore, the research question in this paper is:

Do CareMiles increase the motivation of employees in the health care sector?

Literature review

Motivation and incentives

The goals of organizations in the public sector are different from the goals of private organizations. Instead of having price and profit as important factors, the focus of public

organizations is to meet social needs, like the protection and the promotion of health. Because of this focus it is expected that the motivation of employees in the two sectors are different (Wright, 2001). Public sector employees have the reputation to be lazy. Employees who are motivated to work hard are generally expected to work in a sector where they can earn some kind of reward. In the public sector incentives are less used than in the private sector, so it is expected that only lazy employees work in the public sector, which gives them the reputation that they are lazy (Delfgaauw, 2008, Wilson, 1989; Wright, 2001). Delfgaauw (2008) states that this does not seem to be the case, many employees in the public sector are dedicated to their work. Research shows different conclusions about the motivation of employees in the public sector. The value of employees who chose to work in the public sector are likely to be consistent with the goal of the public organization, which means that the focus is on helping others instead of making profit (Delfgaauw, 2008; Wright, 2001).

It is important to understand employee motivation, because it benefits the organization when the employees are motivated in the right way (Osterloh, 2000). There are two kinds of motivation. The first one is extrinsic motivation, for example (financial) rewards or

compliments. The other one is intrinsic motivation. Intrinsic motivation is caused from within a person. Interesting and enjoyable work, good relationships with colleagues and having the opportunity to achieve something can cause intrinsic motivation (Delfgaauw, 2008; Burgess, 2009; Wright, 2001). The distinction between the two kinds of motivation should be taken into account when incentives are given. Giving extrinsic incentives, while the employees are

intrinsically motivated can lower the effort of the employee (Kreps, 1997). Burgess (2003) states that the extrinsic incentive shows the employee that his effort is appreciated with reference to the company’s profit. This reduces the intrinsic motivation. Intrinsic motivation can sometimes be unclear. It can be caused by extrinsic factors, which makes it difficult to distinguish the two (Krep, 1997).

In the public sector extrinsic incentives are less used than in the private sector, and are therefore also less investigated (Delfgaauw, 2008). There has also been less research done about work motivation in the public sector (Delfgaauw, 2008; Wright, 2001). However, there is some research about work motivation that can be placed in a framework done by Wright (2001). Factors that influence work motivation in the public sector are sector employment choice, employee motives, job satisfaction, job characteristics and work context (Wright, 2001). Those factors can be categorized in employee characteristics (employee motives and job satisfaction) and organizational environment (job characteristics and work context). Work context concerns the characteristics of the firm, like a reward system and the goal of the organization. Sector employment choice is the employees’ choice for the public or the private sector and is the starting point of this framework. Employee characteristics and organizational environment in the public sector differ from those in the public sector.

Wright (2001) states that for this framework it isn’t known if, and how much influence the differences in the sectors have over the individual factors. That there are differences is clear, but what those differences between these two sectors are is not clear, i.e. different researches have shown different conclusions. Besides this it is unknown if these differences actually influence motivation. This leaves us with an incomplete view on work motivation in the public sector. Therefore Wright (2001) comes with a new framework based on the goal theory. Setting up clear and firm, but feasible goals has a positive influence on motivation. Still, goals in the public sector too often seem unclear, unachievable or conflicting. This leads to a decrease in motivation; this is also found in other research (Wright, 2001; Burgess, 2003). Difficult tasks or goals increase effort, because employees judge those goals and the effect of those goals as more valuable than it is the case by easier goals. His framework also contains goal commitment, which consists of importance and self-efficacy. Besides the difficulty, feasibility and clarity, goals should also be important. The importance of a goal can be increased when a reward is linked to it. However, to increase effort there should be a clear link between the goal and the reward, if not, the reward will have the opposite effect (Wright, 2001; Osterloh, 2000).

This is comparable with giving employees extrinsic incentives when they are intrinsically motivated (Kreps, 1997). Decreased motivation as a result of an external incentive is called crowding-out (Osterloh, 2000). The crowding-out theory comes from studies in psychology, but has also been introduced in the economy now. It is the opposite of the better known economic

statement that incentives increase the output. Most economic theories do not take the two kinds of motivation (intrinsic and extrinsic) into consideration, but are only based on extrinsic

motivation. This is because it is difficult to ascertain to what extent the intrinsic motivation actually influences the effort of the employee (Frey, 2001). When intrinsically motivated employees judge an incentive as controlling, the crowding-out effect occurs. The incentive lowers self-esteem and self-determination (Frey, 2001; Deci, 1975). However, crowding-in is also possible, in which case the external incentive is seen as support (Frey, 2001).

Extrinsic motivation is easier to stimulate than the intrinsic motivation. Also it is often unclear if the intrinsic motivation will help reaching the organizations’ goal. However, there are also advantages of intrinsic motivation. For example, intrinsic motivation can help to avoid some problems that occur when incentives are used. There have been found some problems with incentives that especially occur in public organizations. One of them is already mentioned; goals can be conflicting (Burgess, 2003). This can be caused by there being multiple principles, like patients, boards of the health care organizations and insurances; each with their own concerns (Propper, 2003). Each principal will do his best to let his goal seem more important than the others’. Therefore employees will have different tasks between which they will have to divide their attention and effort (Burgess, 2003). When employees are mainly extrinsically motivated they will do their best for the tasks with the biggest reward. Herein the employee would not do what is best for the company (Osterloh, 2000).

Another problem that occurs in both sectors is measuring problems. However, there are some differences as a result of which monitoring the output in the public sector could become more difficult. As there is a less visible output and unclear goals in the public sector, measuring the performance could be a better solution. Monitoring well could also prevent a different problem, namely free-riding. Free-riding could occur, especially when employees are

extrinsically motivated and work in large teams. Keeping teams small and monitoring them can reduce this problem. When team members monitor each other, employees increase their effort because when they are performing weakly there could be a chance of them being fired (Osterloh, 2000).

Besides the differences in kind of motivation some research states that there is a difference in risk-aversion between the two sectors (Buurman, 2012). Job security and more fixed salaries make the public sector more attractive for risk averse employees. Buurman (2012)

also found that public sector employees who just started with their job are more likely to give their reward to a charity. Public sector employees who feel underpaid give less to a charity, they already see their work in the public sector as charity as their compensation is quite low. When employees work longer in the public sector, their attitude changes (Buurman, 2012).

Rank-Order Tournament as reward system

There are different kinds of reward payment methods. One of them is the rank-order tournament, which is first studied by Lazear and Rosen (1981). CareMiles belongs to this type of reward system. The rewards in the rank-order tournament are prizes that are paid as result of the performance of an employee compared to the other employees. Here the rank-order tournament differs from other methods, because those are based on output (Lazear, 1981).

Most knowledge about rank-order is known form theoretical literature, not much empirical research has been done. Some research tested tournaments in sports and compared it with an organizational setting. Becker and Huselid (1992) used data from auto racing. They used this sport, because it is comparable with an organization in collaboration and competition. Their critique at other research that also uses sports, is that those sports do not require collaboration. One of those researches is from Ehrenberg and Bognanno (1990), who tested tournament effects in the individual sport of golf. It is important to look at collaboration, because it influences the company’s performance. Becker and Huselid (1992) state that the tournament system can help motivating employees to work in accordance to the goals of an organization.

A benefit of the tournament is that the prizes are fixed and known. When making the budget the prices can be taken into account in advance. Another benefit is that it is not necessary to know the exact output produced by an employee, because the prizes are given on the basis of relative output. Rank-order tournaments can therefore be preferred when output is difficult or too expensive to measure (Lazear, 1981), like in the health care.

Rank-order tournaments can also be used for selecting employees. For optimal contracts employees should be sorted by ability. When employees are assumed to have the same abilities, selection is not necessary because everyone has the same qualities. In reality employees often have different qualities (Clark and Riis, 2001). However, it does happen that not all information is known by the employees or the employer. Employers have to sort the employees by

information from the past, which can be difficult. For this a rank-order tournament can be used to

select the right person with the best qualities for the job, based on their rank-order position (Lazear, 1981). O'Keeffe et al. (1984) state that when the employer does not know all the information, it is important to use the right prize range when there are more rank-order

tournaments based on the level of ability. For example; one tournament for the employees with high ability and one for the employees with lower ability. In this case there is a probability that high ability employees join the low ability tournament, to win with less effort, O'Keeffe et al. (1984) called this ‘slumming’. The opposite is also possible, whereby low ability employees join the high ability tournament, called ‘climbing’. Slumming can be avoided when the difference in prizes in the low ability tournament are low, and climbing can be avoided when the differences in the prizes are high. This will increase the reliability of self-selection (O'Keeffe, 1984).

However, rank-order tournaments also have some disadvantages. Beside the fact that there is a winner, there will also be some employees who do not perform so well and will end up in the lower positions of the ranking. Those employees can be discouraged by their position and will lower their effort. There is also the possibility that other employees do not want to work with them anymore, because they can lower their performance as well. Another disadvantage is that it can result in cheating and sabotage to prevent that other employees perform better

(Nalebuff and Stiglitz, 1983).

Men and women are not comparable when looking at competitive attitude, which also can result in a disadvantage. Most doctors are men, but the number of female doctors is rising. The CareMiles system is designed for employees in the home care and in nursing homes for the elderly at nursing level. Here most employees are women (Nivel, 2013). Research shows that men and women do not perform equally in competition, especially not in rank-order tournaments (Gneezy and Rustichini, 2004; Niederle and Vesterlund, 2007). Men are more over-confident than women and have a stronger preference for competition. When women have to compete, because it is part of the job, they fail more frequently than men (Niederle, 2007).

Based on the literature, public sector employees are likely to be intrinsically motivated (Wright, 2001; Delfgaauw, 2008). Intrinsically motivated employees can be motivated when the goals are difficult, feasible and clear. To increase employee effort there should be a clear link between the goal and the reward (Wright, 2001; Osterloh, 2000). However, goals in the public sector are mostly conflicting and not clear. Also, the rewards as suggested by the Nationale Denktank, are

not directly linked to the goals. Buurman (2012) states that public sector employees are risk averse, while introducing CareMiles involves the risk of losing. Therefore, hypothesis 1 is: Introducing CareMiles will not increase the motivation of the health care employees.

A disadvantage of a rank-order tournament is that it can result in cheating and sabotage to prevent that other employees perform better (Nalebuff and Stiglitz, 1983). This leads to

hypothesis 2: When the work environment is experienced as not very pleasant, the CareMiles system can result in cheating and negative competition.

In a rank-order tournament men and women do not preform equally, men mostly have a stronger preference for competition and perform better than women. Most employees in the home care and in nursing homes for the elderly are women (Gneezy and Rustichini, 2004; Niederle and Vesterlund, 2007). The difference in preference for competition between men and women has not been tested in the public sector. The motivation of employees in the public sector differs from the motivation in the private sector, therefore it is expected that the preference for competition is also different. This leads to hypothesis 3: There is no difference in opinion between men and women about introducing the CareMiles.

Research methodology

Data

An anonymous survey (see appendix A) is held to test the hypothesis. The survey is held by employees who work in the health care sector. The employees are from different companies, because every organization has a different work environment which can influence the outcome. The employees that filled out the survey come from Dutch companies TZorg, ZZG Zorggroep and Zorggarant. The survey is also posted on the internet at forums for health care employees. The 53 employees that filled out the survey were between the ages of 18 and 60, with an average age of 35.19 years old (SD = 15.55). This is 10 years lower than the Dutch national average age in the health care, which is 45 years (UWV, 2013). Most employees in the health care are women (Nivel, 2013). The respondents of the survey are also mostly female (72.2% of the respondents), as opposed to 27.8% male. From that aspect the test sample is representative. 26.4% of the respondents finished HBO, 24.5% finished HAVO/VWO and 24.5% finished MBO (see table 1). For the analysis of the influence of education only HAVO/VWO, MBO and HBO are used

because this are the general education levels at nursing level, for which CareMiles is designed. Most respondents (81.1%) were not familiar with the idea of CareMiles.

Table 1. Education Percentages of respondents (N=53)

Education Percentage Primary school 3.8 LBO 1.9 MAVO 3.8 VMBO 1.9 HAVO/VWO 24.5 MBO 24.5 HBO 26.4 WO 13.2 Methodology

Age, gender, education, years worked in health care, motivation and work climate.

The survey started with some general questions about the respondent. When analyzing the results age is categorized in 18-25, 26-35, 36-49 and 50 years or older. These questions are followed by questions about motivation and work climate. Work climate could be rated at 5 levels (1 = very unpleasant, 5= very pleasant). These results are categorized in below average (1 and 2), average (3) and above average (4 and 5). The respondents also rated his/her own motivation and the average motivation of his/her colleagues (1= very unmotivated, 5= very motivated). Motivation is also categorized in below average (1 and 2), average (3) and above average (4 and 5).

Kinds of rewards and possible problems.

Respondents could rate the level of motivation they would feel by five different kinds of rewards (1 = by this reward I feel very unmotivated to meet the goal, 5 = by this reward I feel very motivated to meet to goal). The five kinds of rewards were: a social activity with colleagues, a work related course, a gift voucher (for example for a wellness center, clothing of perfumery), something for in your home (kitchen utensils or a painting) and getting paid an extra day of wage. The respondents also rated to what extent three possible problems (freeriding, gossiping and cheating/thwarting) could occur (1 = this will definitely not be a problem, 5 = this will definitely be a problem).

All answers are analyzed with SPSS. To test the hypotheses, the answers to the question ‘Do you think it is a good idea to introduce CareMiles in the health care?’ are specified by gender, work climate, years worked in health care, own motivation and age. Using the Pearson Chi-square test or the Fisher's exact test it can be determined if there is an association between those

characteristics and the respondents’ opinion about introducing CareMiles.

Results

To examine if CareMiles can increase the motivation of employees in the health care, it is tested to what extent employees would feel motivated by five different kinds of rewards. Table 2 shows corresponding frequencies, means and SD for different kinds of rewards rated by the

respondents. These rewards are rated for the level of motivator (1 = by this reward I feel very unmotivated to meet the goal, 5 = by this reward I feel very motivated to meet to goal). All kinds of rewards have an average rating around a score of 3. A score of 3 means that the reward neither increases nor decreases the motivation of the employees. The reward ‘getting paid an extra day of wage’ has been rated the highest (mean: 3.291, SD: 1.1540) and a course as reward the lowest (mean: 2.868, SD: 1.0385).

Table 2:

Frequencies, mean and SD for different kind of rewards (N=53)

Kind of reward Getting paid an extra day wage

An social activity with colleagues Work related course

Gift voucher Something for in your home Mean 3.491 2.962 2.868 3.038 2.358 SD 1.1540 1.2242 1.0384 1.2242 1.0395 Level of motivation 1 = not good motivator, 5=good motivator 1.0 5.7% 11.3% 5.7% 11.3% 24.5% 2.0 11.3% 28.3% 34.0% 24.5% 32.1% 3.0 35.8% 26.4% 37.7% 26.4% 26.4% 4.0 22.6% 20.8% 13.2% 24.5% 17.0% 5.0 24.5% 13.2% 9.4% 13.2% 0.0% Total 100.0% 100.0% 100.0% 100.0% 100.0% 12

Graph 1 shows how many respondents rated the rewards at the possible levels of feeling motivated (1 to 5). The reward that has the highest percentage of fives (reward is very

motivating) is ‘Getting paid an extra day of wage’, and the reward ‘something for in your home’ has the highest percentage of ones (reward is a bad motivator).

Graph 1: Level of motivation for different kind of rewards (N=53) Level of motivation 1 = bad motivator, 5=very motivating

Possible problems are also rated for what extent the respondents expect the problem to occur (1 = will definitely not be a problem, 5 = will definitely be a problem). The mean of the problem that the public classification can cause gossiping is 3.755 (SD: 1.0725), the mean of the ratings for the problem of cheating and thwarting is 2.774 (SD: 1.1871) and the mean of freeriding is 3.528 (SD: 0.9728). Graph 2 shows how many respondents rated the problems and the expected extent of the problems. Freeriding is expected to be a problem by 47.2% of the respondents.

0,0 10,0 20,0 30,0 40,0 1.0 2.0 3.0 4.0 5.0 Percentage Lev el o f m ot iv at io n

Level of motivation

Something for in your home Gift voucher

Work related course Activity with colleagues Getting paid an extra day wage

Graph 2: Possible problems (N=53)

Extent of problem 1 = will not be a problem, 5 = would definitely be a problem

The last question of the survey was ‘Do you think it is a good idea to introduce the CareMiles system in the health care?’. 49.1% of the respondents answered that they think it is a bad idea, 39.6% answered that it sounds like a good idea if the right rewards are used, 3.8% think it is a good idea, and 7.5% think something else which they explained in the comments. For testing the second and third hypothesis these results are specified by personal characteristics (gender, age, own motivation and years worked in health care) and work climate to test if these variables have any influence on the opinion of the respondents concerning the idea of introducing CareMiles. The results are shown in table 3 (N=49). ‘Negative’ means that the respondent is negative about the idea of introducing CareMiles and answered ‘Bad idea’, ‘positive’ means that the respondent is positive about the idea (answered ‘Good idea’ or ‘Sounds like a good idea if the right reward is used’).

For testing if work climate influences the opinion of the respondents the Paerson chi-square test could not be used, because the requirements are not met. 33.3% of the cells have an expected count less than 5. Respondents that rated the work climate of their company as average or below average are slightly more negative about CareMiles, while respondents who rated their work climate as above average are more equally divided between positive/negative.

After that, the Paerson chi-square test of the variable ‘years worked in health care’ is determined, but also did not meet the requirements when three categories (less than 5 years, 5-10

0,0 20,0 40,0 60,0 1 2.0 3.0 4.0 5.0 Percentage respondents Ex ten t o f p ro bl em

Possible problems

Cheating and thwarting Public classification leads to gossiping

years, and more than 10 years) are used. When the categories 5-10 years, and more than 10 years are put together the requirements are met, with p=0.283 so it is not significant. This can be done, because in this way it is possible to test if new employees (<5 years) are more positive about the idea than employees with more experience in the health care sector (≥5 years).

The Fisher's exact test of the variable ‘own motivation’ gave p=0.254. 48.8% of the respondents who rated their own motivation as above average are negative about the idea, while 75% of the respondents who scored their own motivation as average are negative about the idea. But because p >0.05, this difference is not significant.

The respondents in all age categories are equally negative or positive about the idea. The Paerson chi-square test of education is p=0.264, this is larger than 0.05 so it is not significant. Among the employees with MBO as their highest education 66.7% are negative and 33.3% are positive, while this is exactly the opposite for employees with HBO as their highest education.

The results are also specified for gender to test hypothesis 3. 42.9% of the males and 57.1 % of the females are negative about the idea. The Fisher's exact test (two-tail) gave p=0.538, so it is not significant.

Table 3: Percentage respondents negative or positive about idea, specified for characteristics variables. (N=49 for all variables, except education whereby N=36)

Variable Negative (% respondents) Positive (% respondents) Pearson Chi-Square (two tailed) Meet requirements Chi-Square test

Gender Male 42.9 57.1 Fisher's

exact test: 0.528 Fisher's exact test Female 57.1 42.9 Work climate

Below average 60 40 0.401 No, 33.3% of cells have expected count less than 5. Average 64.7 35.3 Above average 44.4 55.6 Years worked in health care (3 categories)

Less than 5 years 46.4 53.6 0.365 No, 33.3% of cells have expected count less than 5. 5 - 10 years 80 20 More than 10 years 56.3 43.8 Years worked in health care (2 categories)

5 years or less 46.4 53.6 0.283 Yes More than 5 years 61.9 38.1

Own motivation Average 75 25 Fisher's exact test: 0.254 Fisher's exact test Above average 48.8 51.2

Age (years) 18-25 50 50 0.937 No, 50% of

cells have expected count less than 5. 26-35 50 50 36-49 60 40 50 or older 50 50

Education HAVO/VWO 50 50 0.264 Yes

MBO 66.7 33.3

HBO 33.3 66.7

Discussion

More and more people need health care. This is caused in part by the rising of the world population but also because the percentage of elderly people is becoming higher. All of these people need health care, this causes the costs to rise. Research and new technologies are also very expensive. To realize all this and to keep health care available for everyone it is important to work efficiently. A possible way to increase the efficiency is to increase the employee

motivation. To achieve this, the Dutch Nationale Denktank has come with an idea in 2011 called ‘CareMiles’. Employees can earn points, called CareMiles, individually or with a team when they meet specific goals. The employee or the team with the most CareMiles at the end of the month gets a reward. The organization may decide what kind of reward. The rewards should increase the motivation of the employee to work hard and efficient.

Incentives are less used in the public sector than in the private sector. Multiple researches indicate that the motivation of employees in the public differ from those of the in the private sector (Kreps, 1997; Wright, 2001; Osterloh, 2000). It is very important to differentiate between intrinsic and extrinsic motivation because otherwise incentives might not have the desired effect. In this thesis the CareMiles system has been researched by the following research question:

Does the CareMiles system increase the motivation of employees in the health care sector?

The first hypothesis was ‘Introducing CareMiles will not increase the motivation of the health care employees’. Respondents could rate five different kind of rewards and to what extent they would feel motivated by them. The five kinds of rewards were: a social activity with

colleagues, a work related course, a gift voucher (for example for a wellness center, clothing of perfumery), something for in your house (kitchen utensils or a painting) and getting paid an extra day of wage. All of the suggested rewards have a mean of around 3. This means that the reward is seen as an average or neutral motivator; it neither increases nor decreases the motivation of the employees. This is in consistent with the hypothesis based on the literature, which state that employees in the public sector are more intrinsically motivated and do not need an external incentive (Kreps, 1997). However, Osterloh (2000) states that the crowding-out effect can occur

when intrinsically motivated employees get an extrinsic reward. This has not been found in this thesis; the rewards do not decrease the motivation of the employees. The kinds of rewards could have influenced this. The rewards can be seen as small and not very expensive. Maybe other kind of rewards and bigger rewards, like a holiday or more job responsibility would show this effect.

Of all kind of rewards ‘getting paid an extra day of wage’ is rated as best motivator, 24.5% of the respondents would be very motivated to meet the goal to get this reward. This is in conflict with the literature, which state that there should be a clear link between the goal and the reward (Wright, 2001; Osterloh, 2000). Based on the literature it is expected that the reward ‘work-related course’ would be the best. However, just 9.4% rated this reward with a 5 (very motivating) and 13.2% with a 4. It can be questioned if a work-related course has a clear enough link to the goal, like said before getting more job responsibility could be investigated as reward. However, in reality it would be difficult to give an employee more responsibility every month. The goals for which the rewards can be earned have a different theme every month, so to get the desired effect the rewards should be adjusted to the theme of the goal of that month.

The respondents could rate the idea of CareMiles positive or negative. Those results are specified for gender, age, own motivation, years worked in health care and work climate. When employees have more work experience and they have worked in a public sector for many years, their attitude changes (Buurman, 2012). Because this could also be the case with CareMiles, the answers are specified for new employees (work less than 5 years in health care) and more experienced employees (works 5 years or more in the health care). The Fisher's exact test found p=0.283 for years worked in health care. P >0.05, so it is not significant. ‘Years worked in the health care’ does not influence the opinion of the respondents about CareMiles. Herein this thesis differs from the literature.

The positive/negative answers are also specified for the different levels of own

motivation that the respondents rated themselves at and for age. 48.8% of the respondents who rated their own motivation as above average are negative about the idea, while 75% of the respondents who rated their own motivation as average are negative about the idea. The Fisher's exact test gave p=0.254, so this is not a significant difference. The respondents in all age

categories are equally negative or positive, so age does not influence the opinion. However, for this analysis four age categories are used to determine if older employees think different about

CareMiles than younger employees. It is possible that these categories have to be sized differently, but is hard to say when an employee is seen as ‘young’ or as ‘older’

The survey provided the respondent the opportunity to write some comments or

suggestions. From the people who filled in a comment, their reactions can be summarized in the sentence: ‘working in the health care is not about earning rewards or CareMiles, but about helping others (see appendix B). However, too few people wrote this to test if this is

representative for the opinion in the national health care, but it is comparable to what is said in the literature about employees in the public sector.

Nalebuff and Stiglitz (1983) state that a rank-order tournament can result in cheating and sabotage to prevent that colleagues perform better, so hypothesis 2 was ‘When the work

environment is experienced as not really attractive, the system of the CareMiles can result in cheating and negative competition’. This could not be tested, just one respondent rated the work climate at his/her work with a 1 (very bad) and just 4 respondents scored his/her work climate with a 2 (bad). These are too few respondents to test if respondents who rate their work climate as (very) bad, expect the possible problems to occur more.

On the other hand, the influence of work climate on the opinion of the respondents could be tested. Respondents who rated their work climate as above average are a little more likely to rate the CareMiles equally as positive as negative, than when the work climate is average or below average. However, there is no significant relationship.

The answers are also specified for gender to test hypothesis 3. The Fisher's exact test for gender is <0.05, so there is no association between gender and opinion of introducing CareMiles. The literature said that men have a stronger preference for competition than women (Niederle, 2007). However, the literature is based on research in the private sector. Because the motivation of the employees in both sectors differs, hypothesis 3 states ‘there is no difference in opinion about introducing the CareMiles between men and women’. The results are consistent with this hypothesis.

Limitations and future research

This study has some limitations. First the number of respondents is not very high (N=54). Especially, for testing the influence of a bad work climate on expected problems there were too few respondents. However, the test sample is quite representative as descripted by the research methodology. The only difference is that the average age of the test sample is 10 years lower than the Dutch national average age in the health care.

The survey was presented within some home care companies, which gave this study another limitation. The employees of home care companies work alone most of the time and do not see their colleagues often. For them it is difficult to rate the motivation of their colleagues and to see if they are putting effort in reaching the goals. Because of this they could rate the idea of CareMiles as a bad idea. However, the Dutch DenkTank also held their pilot at a home care organization. Therefore it would be interesting to compare the results of the pilot with the results of this thesis. As well to investigate why the conclusion of the DenkTank differs from the

conclusion of this thesis. The Dutch DenkTank was contacted for this, but the person with access to the results was temporarily not available due to circumstances.

Another limitation is the survey. With the survey it is only possible to find out what employees think about the idea, how much they think they would feel motivated and in what extent they expect the problems to occur. Future research can investigate the real effects by comparing the results (efficiency, work climate, costs) of an organization before and after

introducing the CareMiles. Also, further research can take a look at the comments of this survey. It would be interesting to investigate if more health care employees share the opinion ‘working in the health care is not about earning rewards or CareMiles, but about helping others’.

When looking at education 24.5% of the respondents finished MBO, 26.4% finished HBO and 24.5% finished HAVO/VWO. The respondents with HAVO/VWO as education are probably doing this as a temporary job in the home care. 13.2 % of the respondents finished WO, these respondents are disregarded in analyzing the effect of education on the respondents’

opinion, because they probably work in the higher levels in the health care, like surgeons or doctors. The CareMiles system is namely designed for employees at nursing level were MBO and HBO are the general education. Further research could investigate if CareMiles work better or worse at different levels of health care jobs, like employees in nursing homes for the elderly, hospitals, different kind of doctors and students with a temporary job.

Conclusion

The research question in this thesis was ‘Does the CareMiles system increase the motivation of employees in the health care sector?’. The hypothesis was ‘CareMiles will not increase the motivation of the health care employees’, because only rewards with a clear link to the goal can possibly increase the motivation of the health care employees. The results of the survey are consistent with this hypothesis. However, expected was that a financial reward would be the least motivating while this reward had the highest percentage of ‘very motivating’. Expected was that a bad work climate would cause the expected problems to occur more. This could not be tested, because there were too few respondents. Also no difference in opinion between men and women could be found. Summarized it can be said that more research about the effect of CareMiles, and the best type of reward is needed. The CareMiles system, designed as investigated in this thesis, would not have the desired effect on the efficiency.

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Appendix A: Enquête beloningssysteem in de zorg

1. Wat is uw leeftijd? ………. 2. Wat is uw geslacht?

a. Man b. Vrouw

3. Wat is uw hoogst afgeronde opleiding? a. Lagere school b. Lager beroepsonderwijs c. MAVO d. VMBO e. HAVO/VWO f. MBO g. HBO h. WO i. Anders:……….. 4. Hoe lang werkt u al in de zorg?

a. Korter dan 5 jaar

b. Langer dan 5 jaar, maar korter dan 10 jaar c. Langer dan 10 jaar, maar korter dan 20 jaar d. Langer dan 20 jaar

5. Welk cijfer geeft u de gemiddelde motivatie van uw collega’s? (1 = zeer ongemotiveerd, 5 =zeer gemotiveerd)

a. 1 b. 2 c. 3 d. 4 e. 5

6. Welk cijfer geeft u uw eigen motivatie?

(1 = zeer ongemotiveerd, 5 =zeer gemotiveerd) a. 1

b. 2 c. 3 d. 4 e. 5

7. Welk cijfer geeft u de werksfeer? (1= zeer onprettig, 5=zeer prettig)

a. 1 b. 2 c. 3

d. 4 e. 5

8. Worden werknemers die zich extra inzetten bij uw huidige werkgever beloont? a. Ja, namelijk door middel van:

b. Nee

Om de stijgende kosten in de zorg te verlagen is er behoefte aan een systeem dat de efficiëntie in de zorg verhoogd. De Nationale Denktank heeft een idee bedacht om dit te bereiken, namelijk door de motivatie van werknemers nog meer te verhogen.

Het idee is als volgt: Elke 6 maanden wordt er een doelstelling vastgesteld binnen een bepaald thema, zoals patiënttevredenheid, kwaliteit van de zorg en collegialiteit. Werknemers kunnen punten behalen wanneer zij aan deze doelstelling voldoen. Deze punten worden CareMiles genoemd. Afhankelijk van de doelstelling kunnen de CareMiles individueel of in een team behaald worden. De werknemer of het team met de meeste CareMiles, krijgt een beloning.

9. Bent u bekend met dit idee? a. Ja, weleens van gehoord.

b. Ja, dit of een vergelijkbaar systeem wordt gebruikt bij mijn huidige of vorige werkgever.

c. Nee, nog nooit van gehoord.

Kunt u aangeven in hoeverre u zich door de onderstaande beloningen meer gemotiveerd zal voelen? (1 = zeer ongemotiveerd, 5=zeer gemotiveerd)

1 2 3 4 5

10.

In hoeverre zou u zich gemotiveerd voelen om de

doelstelling en dus zoveel mogelijk punten te behalen, indien de beloning een teamuitje is? Hierbij kunt u denken aan musical of theater voorstelling, een etentje of high tea.

11.

In hoeverre zou u zich gemotiveerd voelen om de doelstelling, en dus zoveel mogelijk punten, te behalen, indien de beloning een werk gerelateerde cursus is?

12.

In hoeverre zou u zich gemotiveerd voelen om de

doelstelling en dus zoveel mogelijk punten te behalen, indien de beloning een waardebon is? Hierbij kunt u denken aan een waardebon voor een wellness centrum, kleding, parfumerie of een waardebon voor een elektronica winkel.

13.

In hoeverre zou u zich gemotiveerd voelen om de

doelstelling en dus zoveel mogelijk punten te behalen, indien de beloning iets voor in uw huis is? Hierbij kunt u denken aan een koffiezetapparaat, messen- of pannenset, glazen of een schilderij (waarbij u de keuze heeft uit drie modellen).

14.

In hoeverre zou u zich gemotiveerd voelen om de

doelstelling en dus zoveel mogelijk punten te behalen, indien de beloning is dat u een extra werkdag uitbetaald krijgt?

1 2 3 4 5

Het introduceren van de CareMiles zou een aantal problemen kunnen opleveren die een

negatieve invloed hebben op de werksfeer. In hoeverre verwacht u dat de onderstaande stelling voor een probleem zouden kunnen zorgen?

(1= zal totaal geen probleem zijn, 5= zal zeker een groot probleem zijn)

1 2 3 4 5

15.

De punten van elke werknemer worden bij gehouden in een openbaar klassement. Iedereen weet dus van elkaar hoeveel punten ieder heeft. Dit kan leiden tot geroddel over collega’s die weinig punten hebben gehaald.

16. Collega’s zullen elkaar dwars zitten in de werkzaamheden,

om te voorkomen dat de ander punten verdient.

17.

Wanneer de punten in teamverband behaald worden, zal niet iedere werknemer even hard zijn best doen. Dit zorgt voor spanning tussen de teamleden.

18. Wat is uw algemene indruk van het idee om CareMiles the introduceren? a. Slecht idee

b. Klinkt als een goed idee, maar of het werkt hangt af van het type beloning c. Goed idee

d. Anders:

19. Heeft u nog suggesties of opmerkingen over dit idee?

Bedankt voor uw medewerking!

Appendix B: Comments and suggestions of respondents

1. Ik vind het een idioot idee, werken in de zorg gaat over mensen, niet over caremiles 2. Ik vind het belangrijk dat men in functioneringsgesprekken meer positieve bekrachtiging

krijgt en daar zou een beloning aan kunnen hangen, maar niet in competities met andere collega's. Men presteert niet allemaal hetzelfde.

3. Waar veel jongeren (leeftijdscategorie 18 t/m ongeveer 30 a 35 jaar) werken kan dit positief uitpakken.

4. In supermarkten is volgens mij ook al een vergelijkbaar systeem! Ik heb mijn twijfels of het in de zorg zal werken. Of jij persoonlijk of als team goede kwaliteit levert, zou niet uit moeten maken van de beloning die je krijgt. Ik werk in de zorg omdat ik goede zorg voor mensen wil leveren. Ik zou het wel waarderen als je ''punten'' zou verdienen,

wanneer je een extraatje doet voor het team. Waar nu momenteel collega's denken ik laat het liggen, zou dan een beloning tegen over staan. Lastig is wel om dan een waarde aan de punten te kunnen geven. Bij welke activiteit krijg je welke hoeveelheid punten? Grappig idee, maar ik denk niet werkzaam in de zorg.

5. Motivatie komt voor mij niet voort uit extra materiële beloning. Werksfeer en gehoord worden vind ik belangrijker.

6. Doelen moeten duidelijk, helder en haalbaar zijn. Wel binnen de invoedsfeer van de verpleegkundige, geen medische doelen. Leidinggevenden bij voorbaat buitensluiten. Uit groepsonderzoeken blijkt dat het team onvoldoende inzet prima corrigeert. Individuen belonen is zeer slecht voor teamgevoel, het is de betere slijmbal die vaak met de prijs vandoor gaat (gebeurd momenteel op mijn afdeling), de harde zwijgende werker word over het hoofd gezien

7. ik zou het niet willen introduceren, gezien dat de competitie meer zal spelen dan het doel 8. Ben benieuwd, leuk idee maar voor de werksfeer komt het misschien niet altijd ten

goede.

9. Op mijn werk worden beloningen uitgedeeld aan de werknemers die extra hun best doen, echter zijn deze beloningen zeer onterecht. Het is heel moeilijk om daadwerkelijk te checken hoe goed iemand zorg levert. De 'toppers' van ons bedrijf zijn vooral bezig met mailtjes sturen richting het bestuur en zo een wit voetje proberen te halen halen. Terwijl anderen zich de longen uit het lijf rennen en oprecht betrokken zijn bij de cliënten, maar die worden niet opgemerkt.

10. Slecht idee om mensen op deze manier te motiveren. Er zijn op dit moment grote

bezuinigingen bezig, en ik heb niet het idee dat iemand op deze manier van uitgaves zit te wachten. Als je mensen gewoon wilt motiveren zorg dan maar dat de rest op orde is. Dat mensen zich thuis voelen en dat er serieus naar ze geluisterd wordt. Dan is dit soort goedkope omkoping niet nodig.

11. De Gezondheidszorg is een gebied waar mensen bewust kiezen om voor andere te willen zorgen. Dta moet je liggen. Er zijn zeker nog andere methodes om medewerkers

gemotiveerd te houden en te krijgen.

12. ik denk niet dat dit gaat werken aangezien wij onze collega's nooit zien!

13. Ik zie niet zoveel in een beloning als een waardebon of teamuitje, een werkdag extra betaalt zou voor mij meer motiveren omdat mijn salaris nu heel laag is omdat ik leerling ben.

14. Jammer dat dit nodig is om een goede motivatie te krijgen 15. wij werken alleen dus hebben geen collegaas